Summer Program Form CAPTCHA ROWI Summer Program Thank you for your interest in ROWI’s summer programs. Please complete this form to the best of your ability in order for ROWI to facilitate a complimentary clinical assessment with one of our specialists. First Name (Parent/Guardian)(Required)First NameLast Name (Parent/Guardian)(Required)Last NamePhone Number(Required)Please enter a valid phone number.Email(Required) example@example.comClient First Name (Child/Patient)(Required)First NameClient Last Name (Child/Patient)(Required)Last NameDOBDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Client CityInsurance CarrierDesired Facility(Required)BakersfieldBreaBurbankCalabasasCoronaCovinaEncino – KIDS OnlyLake ForestLong BeachPalm DesertPasadenaRancho CucamongaRedlandsTemeculaThousand OaksTorranceTustinSanta ClaritaVistaPlease indicate your preferred schedule below:TEENS (ages 12-17) :Teen Full-Day PHP* (6 Hours) 9:00 AM – 3:30 PM 3:30 PM – 6:30 PM No preference Teen Partial-Day IOP* (3 Hours) 9:00 AM – 12:00 PM 12:30 PM – 3:30 PM 3:30 PM – 6:30 PM No preference KIDS (ages 8-12 – only available in Tustin and Encino) :Kids Full-Day PHP* 8:30 AM – 2:30 PM Kids Partial-Day IOP* 10:30 AM – 1:30 PM 2:30 PM – 5:30 PM No preference *Participation in PHP (Partial Hospitalization Program) or IOP (Intensive Outpatient Program) will be based upon clinical assessment. No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All other categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties. By providing a telephone number and submitting this form you are consenting to be contacted by SMS text message. Message & data rates may apply. You can reply STOP to opt-out of further messaging. CommentsThis field is for validation purposes and should be left unchanged.
