Boston Ability Center Intensive Therapy Interest Form

Boston Ability Center Intensive Therapy Interest Form
Patient's name

First NameLast Name
Patient's date of birth

MonthDayYear
Date
Name of person completing this form

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
My child is...

A current patient (currently receiving weekly services)A previous patient (not currently receiving weekly services)A new patient (never been seen at BAC before)
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
Has your child had any change in functional or medical status over the last year that would be important for our staff to know/that would impact your child's intensive?

Therapy Goals
What are your primary OT related goals for your child's intensive?
What are your primary PT goals related to your child's intensive?
What are your primary speech therapy goals related to your child's intensive?

Location Preference
Do you have a location preference for your child's intensive?

WellesleyNatickNo preference

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

Out of pocket ($150/session + $275/evaluation)Using my insurance benefits (available for BCBS and AllWays only; family may owe amounts associated with copays, coinsurance, and/or deductible depending on insurance plan)

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
1-Week Intensive Self-Pay Policies

Payments:
- Deposit: $200, due at time of registration
- Remaining balance: due 1 week prior to start of intensive
Deposit Refund/Transfer Policy:
- If canceling intensive 1 month or more prior to start, 50% refund of deposit
- If canceling intensive less than 1 month prior to start, no refund of deposit
Session Cancellation Policy:
- No refunds will be issued for missed sessions
- Sessions may be rescheduled if canceled due to illness
1-Week Intensive Insurance Based Policies

Payments:
- Deposit: $200; due at time of registration; 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
- If canceling intensive less than 1 month prior to start, no refund of deposit
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 the box.

FOR MAY/JUNE/JULY INTENSIVES ONLY: I understand that completion of this form does not guarantee my child a spot in an intensive therapy program. Scheduling is subject to availability and I understand that a staff member will be in touch with me as soon as possible to discuss openings.
Please indicate your understanding with the information below by checking the box.

FOR FEBRUARY/APRIL INTENSIVES ONLY: I understand that my request for intensive therapy will not be considered until I have paid a $200 deposit. I understand that submitting this form will lead me to a page where I can complete this deposit, and that from there, a staff member will be in touch to confirm my spots.
Should be Empty:

Boston Ability Center Intensive Therapy Interest Form

Dates and Times Requested

Services Requested

Therapy Goals

Therapy Frequency

Location Preference

Payment Information

Deposit, Payment, and Cancellation Policies

Next Steps