2025-2026 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, providers, and locations), the more likely it is that we will be able to accommodate your request.

    Please Note: This form is only required in order to request a CIMT intensive or a multi-disciplinary intensive (i.e. OT/PT, OT/Speech, PT/Speech). If your family is interested in a single-discipline intensive (i.e. just OT, just PT, or just speech), you do NOT have to complete this form. Instead, please email frontdesk@bostonabilitycenter.com to inquire about availability.

    Thank you!

  • Patient's date of birth*
     - -
  • Format: (000) 000-0000.
  • My child is...*

  • 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 

  • Dates and Times Requested

  • I am interested in having my child participate in a therapy intensive during the weeks below. Please select all timeframes that your child would be available for and please note that the more flexibility provided with timing, the more likely it is that we will be able to accommodate your request!
  • This year, we will be offering morning or afternoon back-to-back session intensives during the approximate timeframes below. Sessions will be 45 minutes each, meaning your child will receive 2 therapies back-to-back for 1.5 hours total. Please indicate your time preference for June 15th - July 3rd.
  • This year, we will be offering morning or afternoon back-to-back session intensives during the approximate time periods below. Sessions will be 45 minutes each, meaning your child will receive 2 therapies back-to-back for 1.5 hours total. Please indicate your time preference for July 6th - July 24th.
  • This year, we will be offering morning or afternoon back-to-back session intensives during the approximate time periods below. Sessions will be 45 minutes each, meaning your child will receive 2 therapies back-to-back for 1.5 hours total. Please indicate your time preference for July 27th - August 14th.
  • This year, we will be offering morning or afternoon back-to-back session intensives during the approximate time periods below. Sessions will be 45 minutes each, meaning your child will receive 2 therapies back-to-back for 1.5 hours total. Please indicate your time preference for August 3rd - August 21st.

  • Services Requested and Frequency

  • Please indicate which therapies you would like your child's intensive to include.
  • 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.
  • Would you like your child's intensive to include Constraint Induced Movement Therapy (CIMT)?
  • Would you be interested in a 3-hour, daily CIMT intensive for your child? (PLEASE NOTE: Insurance will only cover one 45-minute session per discipline per day. The rest of the time in services would be at a self-pay rate of $150/hour)

  • Therapy Goals

  • Location Preference

  • Do you have a location preference for your child's intensive? Please note that our clinicians split their time between our two offices, so flexibility for your child to be seen in either office may result in greater clinician continuity.

  • Payment Information

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

  • 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

  • Please indicate your understanding with the information below by checking each box.
  • Should be Empty: