Caregiver Consultations

BIRTH AND MEDICAL INFORMATION
Does your child have any formal diagnoses?*
Does your child have any other health issues or medical precautions that we should be aware of?*
Is your child adopted? If so, at what age?*
Was your child born premature or full-term?*
Did your child spend any time in the NICU?*
Please select any assistive devices that your child uses (if applicable)*

Glasses or contact lenses (Consistently or for specific circumstances? Please specify below)Hearing aidsCochlear implantAugmentative and alternative communication device (please specify below)Mobility devices (please specify below)Orthotics/bracing (please specify below)Other (please specify below)None of the above
Please specify the information provided above:

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
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 that would be helpful for the consulting clinician to review (IEPs, progress reports, recent evaluations, etc.)

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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.
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Parent's name*

First NameLast Name
Date*

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Date

Additional information
Is there any additional information that you would like to share?
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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BIRTH AND MEDICAL INFORMATION