2024-2025 BAC Intensive Therapy Interest Form

Boston Ability Center Intensive Therapy Interest Form
Thank you for your interest in intensive therapy services at the Boston Ability Center! Intensives at BAC are based on clinical recommendations and schedule availability. Please fill out this form in its entirety and a member of our team will be in touch as soon as possible to let you know if we are able to accommodate your request. Please note that the more flexibility your family has (with regards to dates, times, and locations), the more likely it is that we will be able to accommodate your request. Thank you!

Patient's name*

First NameLast Name
Patient's date of birth*

MonthDayYear
Date
Name of person completing this form*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
My child is...*

A current patient (currently receiving weekly services)A previous patient (not currently receiving weekly services)A new patient (never been seen at BAC before)
STOP!

Welcome to the BAC! We are excited to work with you and your child. In addition to completing this form, we ask that you please complete 2 additional forms (linked below). This will provide us with all of the information we need to determine what services/intensives will be the best fit for your child.

1. Intake form

2. Developmental summary form
Has your child had any change in functional or medical status over the last year that would be important for our staff to know/that would impact your child's intensive?*

Services Requested and Frequency
Please indicate which therapies you would like your child's intensive to include.

Occupational TherapyPhysical TherapySpeech/language Therapy
Intensives can be scheduled for 3, 4, or 5 days per week. Please indicate how many days per week you are interested in having therapy services as part of an intensive.

3 days4 days5 days
For each discipline selected above, please list the APPROXIMATE frequency at which you would like your child to receive each therapy (ex: OT 5x/week, PT 3x/week, Speech 2x/week). Please note that final schedules may depend on clinical recommendations and availability.
Would you like your child's intensive to include Constraint Induced Movement Therapy (CIMT)?

Yes, and my child has a cast that will fit themYes, and my child will need a cast made ($200 self-pay cost)No

Therapy Goals
What are your primary OT related goals for your child's intensive?
What are your primary PT goals related to your child's intensive?
What are your primary speech therapy goals related to your child's intensive?

Location Preference
Do you have a location preference for your child's intensive?

I can only go to WellesleyI can only go to NatickI prefer Wellesley but will go to Natick if necessaryI prefer Natick but will go to Wellesley if necessaryNo preference

Payment Information
I intend to pay for my child's intensive therapy services...

Out of pocket ($150/session + $275/evaluation)Using my insurance benefits (available for BCBS and Mass General Brigham Health Plans only; family may owe amounts associated with copays, coinsurance, and/or deductible depending on insurance plan)

Deposit, Payment, and Cancellation Policies
3-Week Intensive Self-Pay Policies

Payments:
- Deposit: $200/week + $100/eval; due within 1 week of confirmation
- Remaining balance: due 1 month prior to start of intensive
Deposit Refund/Transfer Policy:
- If canceling intensive 1 month or more prior to start, 50% refund of deposit ($250 may be applied towards future services within 6 months)
- If canceling intensive less than 1 month prior to start, no refund of deposit ($250 may be applied towards future services within 6 months)
Session Cancellation Policy:
- No refunds will be issued for missed sessions
- Sessions may be rescheduled if canceled due to illness
3-Week Intensive Insurance Based Policies

Payments:
- Deposit: $200/week + $100/eval; due within 1 week of confirmation; returned at conclusion of intensive (less any cancellation fees as outlined below)
- Payments: collected daily at time of service (amounts associated with copays, coinsurance, and/or deductible depending on insurance plan)
Deposit Refund/Transfer Policy:
- If canceling intensive 1 month or more prior to start, 50% refund of deposit ($250 may be applied towards future services within 6 months)
- If canceling intensive less than 1 month prior to start, no refund of deposit ($250 may be applied towards future services within 6 months)
Session Cancellation Policy:
- $100 cancellation fee per session canceled less than one month prior to start of intensive (cancellation policy does not apply if canceling entirety of intensive; see deposit refund/transfer policy above)
- $150 no-show fee per session
- Sessions may be rescheduled if canceled due to illness

Next Steps
Is there any additional information you would like to share?
Please indicate your understanding with the information below by checking each box.

I understand that completion of this form does not guarantee my child a spot in an intensive therapy program. Scheduling is subject to availability and I understand that a staff member will be in touch with me as soon as possible to discuss openings.I understand that intensive therapy services may involve more than one clinician per discipline, based on availability. I understand that if scheduled, my child's clinicians will collaborate closely to ensure continuity of care.
Should be Empty:

Boston Ability Center Intensive Therapy Interest Form

Dates and Times Requested

Services Requested and Frequency

Therapy Goals

Location Preference

Payment Information

Deposit, Payment, and Cancellation Policies

Next Steps