SUMMER DAYTIME Services - Intake Form

Our clinic will be open from July 6th - August 21st for daytime services.  Services will run on Monday and Wednesday afternoons from 1:00 - 4:00, Tuesday and Thursday mornings from 9:00 - 12:00, and all day Friday from 9:00 - 3:00.  Our wonderful behavior therapists are available to carry over programming to our clinic setting to ensure your child will have no break from services, or to provide additional sessions to your child's summer services.

**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 program.**

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

Parent/Caregiver information
Person completing form *
Person completing form
e.g. parent, teacher, etc.
Student information
Student's Name *
Student's Name
Please list any food or medication allergies.
Please list any relevant medical history (seizure disorders, visual impairments, etc.)
Date of birth *
Date of birth
Modes of communication
Please select any/all modes of communication reliably used by your child.
Please list goals for your child. This might include skills to work on or behaviors to decrease.
Please list any challenging behaviors that your child engages in.
Please list any items or activities your child is interested in or enjoys engaging in.
Scheduling/Availability *
Please select all sessions that you are interested in.
Please select how the services will be funded.
Please let us know about any scheduling questions or concerns you may have related to the available session times.