Home-Based OT Interest Survey

Thank you for your interest in home-based OT services through the Boston Ability Center! BAC is always eager to find new ways to support children and families, and we are looking into the possibility of bringing our expertise to the convenience of your home! Home-based services provide opportunities for parent/caregiver collaboration, allow for the practice of targeted skills within a child's natural environment to promote carryover and generalization, and can allow for in-the-moment problem solving when challenges in daily activities arise.

If you are interested in home-based services, we ask that you please answer the questions below to the best of your ability. Please note that services are not guaranteed, however providing this information will allow our team to assess interest in these services and explore programming possibilities to meet the needs of families in our community. We will be sure you keep you informed of any new service delivery options once available.

Please note: At this time, we are primarily looking to pilot home-based occupational therapy services, and as such we ask you to please focus your responses below on interest in home-based OT.

Child's Name

First NameLast Name

Child's Date of Birth

Date

Parent/Caregiver's Name

First NameLast Name

Patient's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address

example@example.com

My child

I am interested in home-based OT services:

Patient's Insurance

I am interested in home-based OT services...

I am interested in in-home OT services targeting... (please check all that apply)

We anticipate that in-home OT services will require a self-pay convenience fee to offset the cost of travel and travel time. This convenience fee would be in addition to copays/deductibles/coinsurance amounts (if services are billed through insurance) or the price of a session (if self-pay). Please use the slider below to select the number that best completes the following statement: "A convenience fee of $____ or more would prohibit my family from being able to access home-based OT services."

Home-based OT services would be ideal for my family during the following days and times:

It is likely that in-home OT services would be piloted on Tuesday afternoons/evenings (2pm or later).

Do you have more than 1 child who you would like to receive in-home OT services back-to-back?

Please keep me informed about in-home service options for... (check all that apply)

Home-Based Occupational Therapy Services