Boston Ability Center Intake

New Patient Intake
Thank you for your interest in services at the Boston Ability Center!

We will need a bit of information to get started... it may seem like a lot but a few minutes of your time upfront will help us to provide the best care possible! Please note that you MUST upload a copy of your insurance card in order to complete this form, so please have it on hand!

Prefer to give your information over the phone? Give us a call at 781-239-0100 and a member of our front desk team would be happy to help.

PATIENT INFORMATION
Child's Name:*

First NameLast Name
Name we should call your child at our clinic*
Child's Date of Birth:*
Child's Pronouns*
Child's Gender*

MaleFemaleNon-BinaryOther
For insurance purposes:
Child's name as communicated to insurance company (if different than above)
Child's sex as communicated to insurance company

MaleFemale
Child's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Caregiver 1 Name*

First NameLast Name
Parent/Caregiver 1 Phone*

Area CodePhone Number
Parent/Caregiver 1 Email*
example@example.com
Parent/Caregiver 1 relationship to patient*
Parent/Caregiver 1 Information*
Parent/Caregiver 2 Information (if applicable)
Names/relationships of other individuals regularly involved in child's care (i.e. grandparent, nanny, babysitter)
Please list any language(s) spoken in your child's home*
Has your child received services at the BAC previously?*

YesNo

RELATED SERVICES AND PROVIDERS
Has your child had any previous EVALUATIONS? If so, please list approximate date and provider.
Has your child received any of the following services PREVIOUSLY? If so, please list provider and approximate dates of services.
Does your child receive any of the following services CURRENTLY? If so, please list provider and how long your child has been receiving that service.
Does your child receive any of the following supports at school?*

IEP504In the process of evaluating for IEPNone of the aboveOther
When was your child's last 3-year IEP evaluation?*
Please list services currently provided as part of your child's IEP*
Please list any other specialists/providers that your child is currently followed by (ex: cardiologist, neurologist, orthopedist, orthotist, gastroenterologist, behavioral supports, neuropsychologist/psychologist, etc.)
Please upload any recent reports regarding your child's care (IEPs, progress reports, recent evaluations, etc.) This allows your child's clinician to prepare accordingly prior to the evaluation. Don't have them handy? No worries - please email them to frontdesk@bostonabilitycenter.com. It is important for us to receive prior evaluations and reports before your child's first appointment.

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REFERRAL SOURCE
How did you hear about us?*
Child's Pediatrician:*
Pediatrician's Practice:*
Pediatrician's Phone Number*

Area CodePhone Number
Pediatrician's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like a copy of your child's evaluation report(s) to be sent to your child's pediatrician?*

YesNo

SCOLIOSIS INFORMATION
Has your child had a recent Physical Therapy evaluation done?*

YesNo
Has your child ever had Physical Therapy for their scoliosis?*

YesNo
Please indicate where your child has received physical therapy services previously.*
Does your child have recent x-rays? If so, please send to frontdesk@bostonabilitycenter.com.*

YesNo
Does your child wear a brace?*

YesNo
Please indicate who your child's orthotist is.*
Who is your child's orthopedist/orthopedic surgeon? *
Please note the following important information pertinent to your child's scoliosis evaluation:
- Boys will be asked to remove their shirt for the evaluation. Girls are asked to wear a camisole or a sports bra with parallel straps (no racerback or "y" back shirts).
- Photographs will be taken at your child's evaluation for the purpose of scoliosis classification and progress monitoring. These photographs are for use only by the physical therapist and your family.
- Please bring a copy of your child’s x-ray if you did not send a digital copy to the Frontdesk
- Please bring your child’s back brace to the evaluation if they wear one.

INSURANCE INFORMATION

PLEASE NOTE: If you have Mass General Brigham Health Plan as your insurance provider, your child is the "subscriber" and has their own ID number separate from their guardian.
Does your child have secondary insurance? If so, please specify what your child has as secondary insurance. *
Primary Insurance Subscriber's Name (as communicated to insurance company):*
Primary Insurance Subscriber's Date of Birth:*
Primary Insurance Subscriber's Gender (as communicated to insurance company):*
Primary Insurance ID Number (including prefix, if applicable)*
Primary Insurance Group Number*
Please upload a picture of the FRONT of your insurance card. PLEASE NOTE! If you have Mass General Brigham Health Plan, please upload your CHILD's insurance card (not your own), as cards for MGB have different numbers for each insured individual*

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Please upload a picture of the BACK of your insurance card.*

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EVALUATION REPORT
Our standard evaluations are 1 hour long and include a short summary of testing results, therapy goals, and a plan of care. The goal of these evaluations is to establish a plan of care and provide enough information to allow your child to get started with services. Additional information will likely be collected during your child's first few therapy sessions.*

I understand and would like to proceed with the standard evaluation reportI am interested in learning about an extended report option (not an option for PT, feeding, and AAC evaluations)
For OT and Speech evaluations, you may opt for a more in depth report of evaluation findings for an additional out of pocket fee of $150 (not an option for PT and feeding evaluations). This report will include additional explanation of assessment results and clinical reasoning. While standard evaluation reports are sufficient for most patients, some families find extended evaluation reports helpful if they would like to share evaluation results with their child's school or other providers. Please indicate below what type of report you would like following your child's evaluation. Please note that your child's evaluation will still be 1 hour long regardless of which report you select.*

I would like an extended evaluation report for the additional self pay charge of $150I would like the standard evaluation report (included in the price of my child's evaluation)

EVALUATION REPORT
Our standard evaluations are 1 hour long and include a short summary of testing results, therapy goals, and a plan of care. The goal of these evaluations is to establish a plan of care and provide enough information to allow your child to get started with services. Additional information will likely be collected during your child's first few therapy sessions.*

I understand and would like to proceed with the standard evaluation report included in the cost of my child's evaluation ($275, or $550 for feeding evaluations)I am interested in learning about an extended report option (not an option for PT, feeding, and AAC evaluations)
For OT and Speech evaluations, you may opt for a more in depth report of evaluation findings for an additional out of pocket fee of $150 (not an option for PT and feeding evaluations). This report will include additional explanation of assessment results and clinical reasoning. While standard evaluation reports are sufficient for most patients, some families find extended evaluation reports helpful if they would like to share evaluation results with their child's school or other providers. Please indicate below what type of report you would like following your child's evaluation. Please note that your child's evaluation will still be 1 hour long regardless of which report you select.*

I would like an extended evaluation report for the additional self pay charge of $150I would like the standard evaluation report (included in the price of my child's evaluation)

Weekly Availability Form

Please provide your weekly availability. We make every effort to provide your child with a weekly standing appointment. If a weekly appointment that fits your schedule is not immediately available, we recommend getting on our cancellation call list. If your availability changes at any time, please let us know. Thank you!
Please note: If your family has morning or midday availability, it is likley that we will be able to get you scheduled sooner.
Location Preference (PLEASE NOTE: wait list times vary for each of our locations. Our offices are 10 minutes apart. We encourage you to get started by taking the first available appointment that fits your schedule in either location, and we are happy to keep you on our wait list for times in your preferred location).*

I will ONLY be seen at the Wellesley office (49 Walnut Park, Building 3, Wellesley Hills, MA)I will ONLY be seen at the Natick office (10 Tech Circle, Natick, MA)I prefer the Wellesley office but am willing to get started in either locationI prefer the Natick office but am willing to get started in either locationNo preferenceI would like services conducted via telehealth

Please list ALL availability by location and day. Please be as specific as possible, including the earliest time you can arrive for an appointment and the time by which you would need to leave.*

	Wellesley Availability	Natick Availability
Monday (BAC open 7am-6:30pm, Aquatic OT and PT available from 7-10am)
Tuesday (open 7am-6:30pm)
Wednesday (open 7am-6:30pm)
Thursday (BAC open 7am-6:30pm, Aquatic OT, PT, and Speech available from 7-9am)
Friday (open 7am-5:30pm)
Saturday (open 8am-2:30pm)

Additional scheduling notes/comments.

A FEW NOTES TO GET YOU STARTED

Questions? Give us a call at 781-239-0100.
Please indicate understanding of the following by initialing: *
Should be Empty:

New Patient Intake

PATIENT INFORMATION

MEDICAL INFORMATION

SERVICES NEEDED

Important Feeding Evaluation Information

RELATED SERVICES AND PROVIDERS

SCHOOL INFORMATION

REFERRAL SOURCE

SCOLIOSIS INFORMATION

INSURANCE INFORMATION

INSURANCE INFORMATION

EVALUATION REPORT

EVALUATION REPORT

Weekly Availability Form

A FEW NOTES TO GET YOU STARTED