SUMMER VACATION Services - Intake Form

Our clinic will be open during the weeks between the regular school year and the beginning and end of your child's summer services.  Our clinic vacation hours are Monday - Friday from 9:00 am - 3:00 pm during the following dates; June 15th - July 2nd and August 17th - August 28th.  There will be no clinic session on Friday, July 3rd. Students can sign up for any or all days, and one or both sessions offered each day (9am-12pm, 12pm-3pm).  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 break up those long days at home while school is out.

**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.