• Caregiver Consultations

    Through The Boston Ability Center
  • Child's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • I am interested in a parent consultation with:*
  • My child*
  • My child*
  • My child*
  • Primary Insurance Provider*

  • Thank you for your interest in parent consultation services! Based on the information that you provided, parent consults would be self-pay. Consultation sessions will be 45-minutes and cost $165. 

  • Thank you for your interest in parent consultation services! Based on the information that you provided, we anticipate that your insurance plan will cover parent consultation services in the same way as in-clinic therapy services, as long as these consultations occur IN-CLINIC. You will still be responsible for copays, deductibles, and coinsurance amounts as outlined by your plan. If you would like a consultation via zoom, it will be at a self pay rate of $165 for a 45 minute consultation.

  • BIRTH AND MEDICAL INFORMATION

  • Please select any assistive devices that your child uses (if applicable)*

  • 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?*

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  • SCHOOL INFORMATION

  • SOCIAL EMOTIONAL OBSERVATIONS

  • Do you have any concerns surrounding your child's social/emotional development or executive functioning?*
  • What concerns do you have regarding your child’s social-emotional development? Please check all that apply:*

  • How often do self-regulation challenges occur?*
  • When upset, how long does it take for your child to calm?*
  • What do self-regulation challenges look like for your child? Please check all that apply:*

  • What calming/coping strategies have you tried?
  • Are there any specific triggers for self-regulation challenges? If so, please explain:*

  • FEEDING OBSERVATIONS

  • Do you have any concerns surrounding your child's feeding?*
  • GI: (please check all that apply)*
  • Respiratory: (please check all that apply)*
  • Behaviors observed during feeding: (please check all that apply)*
  • Please check the methods of consumption your child has used/currently using:*
  • Please check the methods of consumption your child has used/currently using:*
  • Check All That Apply*

  • Boston Ability Center Scheduling Policies

    Please initial each of the items below to indicate understanding of our cancellation and missed session policies for parent consultation sessions.
  • *
  • *
  • *
  • *

  • Thank you for choosing the Boston Ability Center. We are so excited to get to know you and your child!

     

    I understand and agree to adhere to the appointment policy.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Report Selection

  • A write-up of items discussed during the consultation as well as additional personalized recommendations and/or home programming can be obtained for a self-pay cost of $150. Please let us know below if you would like this report.

  • Additional information

  • Thank you for your interest in parent consultation sessions through the Boston Ability Center! Please press the button below to submit this form and a member of our team will be in touch shortly to discuss further.

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