Teencamps-UK Application and Assessment Form

Teencamps-UK Application and Assessment Form

** Please give as much detailed information as possible in your answers as this will be used to assess if your young person will be suitable to attend a camp**
Information that we require
Which type of camp/ service are you applying for? Please only tick the actual services you require *

UK Male Group Camp Individual Therapeutic Retreat in Spain- 7 day minimum Individual/ Family Therapeutic Home Intervention in UK or International- 3 day minimum Skype Online Consultancy
Dates required? Please only tick the dates you want your child to attend *

Individual Therapeutic Retreat in Spain- 7 days @ £2800.00 per week (Sunday to Saturday unless otherwise agreed. Additional days at £400.00 per day (full or part). Please email dates requested. Individual/ Family Therapeutic Home Intervention in UK or International -3 days @ £1800.00 plus expenses. Additional days can be added @ £600 per day plus expenses. Please email dates requested. Skype Online Consultancy @£120.00 per 60 min session. Please email suitable dates and times.
Optional Services
Are any Optional Services required? *

Alicante Airport, Spain Individual Therapeutic Retreat- Pick up/ Drop off @ £180.00 Written Report for UK group camp only @ £320.00 None - No optional extras required
Young Persons Details
Full Name of Young Person *

First Name Middle Name Last Name
Age *
Date of Birth *
Gender *

Male Female
FULL details of issues and family history. Give as much information as possible *
WHAT does the family hope this camp will achieve? *
How would you describe your parenting style? *
Are you open to changing your parenting style if necessary? *
Has the young person had Counselling previously? If Yes then please give full details *
Do they have any mental health issues or have they been hospitalised? If yes then please provide details *
Are they on any medication? If yes then please provide details. *
Have they ever self harmed? If Yes then please give details *
Do they use drugs or alcohol? If Yes then please give full details *
Do they have a disability? If Yes then please give full details *
Do they have any criminal convictions or any court cases pending? If Yes then please give full details *
Are they in education? If Yes then please give full details including school address *
Are they involved with any external Services? If Yes then please give full details *
Do they have any allergies? If Yes then please give details *
Do they have any special diet requirements? If Yes then please give details *
Does the young person speak fluent English? *
Where did you hear about Teencamps-UK? *
Parents / Guardian Details
Parent / Guardian FULL NAME *

First Name Last Name
FULL address and postcode *
Telephone Number? *
Email Address? *
Payment Method
I agree to pay by *

BACS
Terms and Conditions
I have read, understood & agree to Teencamps-UK Terms & Conditions. *

Yes
I agree that I will collect my young person from camp if they are dismissed or if I chose to remove them. *

Yes
Should be Empty:

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Teencamps-UK Application and Assessment Form

Information that we require

Optional Services

Young Persons Details

Parents / Guardian Details

Payment Method

Terms and Conditions