Stepping Forward Counseling Center, LLC
Therapeutic Summer C.A.M.P.
Clinically Advanced Multi-Modality Program

Application for: *
Contact & Background Information
Child Lives With *
Parent/Guardian 1 Information:
Parent/Guardian 2 Information:
Persons to be Contacted in Case of Emergency If Parent/Guardian Cannot Be Reached:
Emergency Contact 1
Emergency Contact 2
Special Requests:
Please list ALL allergies and special dietary needs that pertain to your child
Please list ALL medications and dosage that have been prescribed to your child
Below, please check off the weeks your child will be attending. Please note that a requirement of the program is that your child must be enrolled for at least three consecutive weeks. If your child is signed up to attend the program for nine or more weeks, they will be scheduled to meet with the psychiatrist for a psychiatric evaluation.
Day C.A.M.P. Dates (CHATHAM, NJ): Please select the dates your child will be attending
Day C.A.M.P. Dates (YORBA LINDA, CA): Please select the dates your child will be attending
Day C.A.M.P. Dates (IRVINE, CA): Please select the dates your child will be attending
  * Dependent on the number of registered campers
** SFCC will be closed 07/04 for the holiday
  - Please note pick-up times may vary, so please check the field trip schedule
  - Fridays are early dismissal, pick up is at 1 pm
Additional Services:
Please check the services required for your child (additional fees will apply)
Early drop off ($20/hour, 8:00AM-9:00AM) *
Late pickup ($20/hour, 3:00PM-5:30PM*) *hours vary by location. Check with your location! *
T-Shirt Information Please check size for the FREE T-Shirt for Summer of 2024 (Predict size in summer) Additional T-Shirts may be purchased for $20 each *

Published rates are for Cash and Schools only. Other institutions are billed at a higher rate. The client is ultimately responsible for payment of all charges identified as “due amounts” which include: insurance payments forwarded to the client, deductibles, co-payments, intake fees, reinforcement fees, missed appointment fees, application fees, and other fees and costs delineated by SFCC. SFCC shall submit applicable due amounts (identified as “insurance billed amounts”) for reimbursement to the client's insurance provider. Failure to pay insurance proceeds received by the member shall be subject to collection by SFCC with the client being responsible for all costs of collection, including attorney fees. Stepping Forward owns and operates licensed and/or accredited mental health treatment centers and therapeutic summer programs. The length of stay and level of clinical intervention determine the cost of each program. Tuition/fees may range from $400.00 to $65,000.00 and may be supplemented by a sliding scale, insurance, scholarships, or agreements to pay. Many of our programs are contracted with insurance carriers, scholarships, and school programs. Parents are encouraged to contact SFCC directly to request assistance with obtaining payments and insurance coverage.
School Reimbursement
Insurance Information
Please submit insurance information ASAP

Credit Card / Check Information
Please note that the $400.00 non-refundable processing fee must be included with the application. Your application will not be processed until the fee is received.
Enclosed is my *
Billing Address
Enrollment Questionnaire-Counselor's Insight
Please Provide the Important Information Below:
16. What is the swimming experience for your child? Select one.
*Decision for formal enrollment to the program is based upon personal interview, observation, and review of supportive information, after receiving the completed application and processing fee of $400.00. Please call your local Stepping Forward Counseling Center as soon as possible to set up an appointment (Chatham, NJ: (973) 635-6550 • Yorba Linda, CA: (714) 340-0511 • Irvine, CA: (949) 333-1209).
                                                    Parent Authorization

1.     I agree to pay the annual tuition. Pre-payment is due prior to the start of camp. In the event of 3rd party payment all claims are due to Stepping Forward Counseling Center, LLC. In the event a check(s) is/are received from an insurance provider and/or school, it is agreed that said check(s) will be designated as “payable to Stepping Forward Counseling Center” and the check(s) and explanation of benefits will be immediately forwarded to Stepping Forward.

2.     No refunds will be made for incidental absences or after camp has started.

3.     Stepping Forward is not responsible for any camper’s belongings, either lost or damaged, while attending.

4.     If either parent or the emergency contacts cannot be contacted in an emergency, I hereby give Stepping Forward consent to bring my child to an emergency room or medical professional and authorize Stepping Forward to provide consent to secure necessary and proper medical treatment. I hereby authorize and direct Stepping Forward to administer medication as set forth in this application.

5.     Permission is hereby granted to the Director of Stepping Forward to take my child on field trips as part of the regular program.
6.     Permission is hereby granted for photographs to be taken of my child during activities and Stepping Forward has the right to utilize these photographs in promotional materials.

7.     My child has permission to engage in all prescribed program activities, except noted on the required medical form.

8.     Permission is hereby granted to Stepping Forward to transport my child to and from any off-site activities.

9.     Permission is hereby granted to Stepping Forward counselors to apply sunscreen to my child.
Stepping Forward
Counseling Center, LLC
Therapeutic Summer Camp
Medical Treatment Consent Form
I give my consent for Stepping Forward Counseling Center to take any medical emergency treatment precautions necessary in case of injury or illness to ensure the safety of my dependent. I give permission for SFCC to provide first aid, and to contact the Emergency Medical Service to transport my dependent to the nearest hospital in order to treat him/her with serious injury and/or illness while on-site, or on off-site trips.
Signature of Parent/Guardian *
Special Requests
Child Immunization Record
*To be completed by Physician's office.
Provisional Admission:
Medical Exemption:
Religious Exemption: