Camp Therapyology Registration Form

Camp Therapyology

Registration Form for Camp Therapyology
Therapyology will be offering the following camps:

- Rainbow Camp (LGBTQIA+ tweens/teens)

- 'You CAN Sit With Us' Girls' Camp (middle school & high school girls)

- Camp Therapyology (week-long camp of fun and building social connection)

*Please fill out this form with as much information as possible. This form is required to be considered for participating in our group programming but does not guarantee a spot

**While privacy and confidentiality will be strongly encouraged, we can not 100% guarantee (given in a group setting) that confidentiality will adhere to by every group member.
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Gender

MaleFemaleNon-BinaryOther
Personal Pronouns

She/her/hersHe/him/hisThey/them/theirsOther
Participant Phone Number
Participant Email
example@example.com
Emergency Contact

First NameMiddle NameLast Name
Emergency Contact Email
example@example.com
Emergency Contact Phone Number
Group interested in

Camp Therapyology (July 18 - July 22)Rainbow - Middle SchoolRainbow - High schoolYou Can Sit With Us! - High SchoolYou Can Sit With Us! - Middle SchoolYou Can Sit With Us! - CollegeI do not see the group I want but I want someone to contact me
Background Information
Tell us a little about yourself and why you want to join the Camp Therapyology?
Have you (the participant) attended therapy before? Are you currently in therapy?
Have you (the participant) been hospitalized? If so, please explain.
Do you have a history of self harm, suicide idealization, suicide attempt, or homicide idealization? If so, please explain.
Please use this space to write down anything else you feel might be important for us to know as we consider participants into our program:
Should be Empty:

Camp Therapyology

Background Information