make-up Services - Intake Form

Our clinic will be open Friday nights from 3:00 pm - 8:00 pm, Saturdays 12:00pm – 6:00pm, and Sundays 9:00am – 5:00pm for the remainder of the winter weather months.  Students can sign up for any or all days to make up previously cancelled sessions.  Our wonderful behavior therapists are available to carry over programming to our clinic setting to ensure your child will have access to their regularly scheduled home programming. 

**Please note, filling out this form does not guarantee enrollment. Our Clinic Manager or Intake Coordinator will be in touch to confirm your spot in the clinic for makeup sessions.**

For help in filling out this form, or for more information about our makeup services, please contact or call 617-505-6183.

Parent/Caregiver information
Person completing form *
Person completing form
Student information
Student's Name *
Student's Name
Please list any food or medication allergies.
Scheduling/Availability *
Please select all sessions that you are interested in.
Please let us know about any scheduling questions or concerns you may have related to the available session times.