Schedule Request Form

Schedule Request Form

Thank you for your patience as we work to find all families appointment times that work well for their schedules! Please complete ALL information found below, as this will help us to get you scheduled as quickly as possible.
Child's name*

First NameLast Name
Child's DOB:*

MonthDayYear
Date
Name of person completing this form*

First NameLast Name
My child...*

is currently receiving servicesreceived services previously and I would like to resume
Please list the appointment days and times that you would like to change*
On what date would you like to start a new appointment time? (please be as specific as possible, such as "the week of ___")*
If a new appointment time becomes available earlier (i.e. before the start date you listed above), are you able to take it earlier or should we offer it to the next person on the wait list? If you are able to take it earlier, what is the earliest date you could take a new spot by?*

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 (open 7am-6:30pm)
Tuesday (open 7am-6:30pm)
Wednesday (open 7am-6:30pm)
Thursday (open 7am-6:30pm)
Friday (open 7am-5:30pm)
Saturday (open 8am-2:30pm)

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 any providers you prefer to have your child work with:
Provider Preference

I am only interested in appointments with the clinician(s) listed aboveI prefer for my child to work with the clinician(s) above, but if a spot with them is not available within my child's availability, I am open to seeing a different provider
Are you able to keep your current appointment time until a new spot becomes available?*

No, please discontinue the appointments listed previously, effective immediatelyYes, I can keep these spots indefinitely but would like to be notified as soon as my preferred time becomes availableYes, I can keep these spots short-term, but only until a certain date
When is the last date that your current appointment time(s) will work for you? (please note, all sessions after the date listed below will be removed)*
If we can't find a new weekly appointment that works for your family by the date requested, would you like to be on our cancellation call list and receive updates of 1x appointments as they become available?

Yes, I would like my child to be seen during cancellation openings until a weekly appointment becomes availableNo, I would only like you to reach out once a weekly appointment becomes available
Is there anything else you would like to share?
Should be Empty: