School Vacation Services - Interest Form

Our clinic will be open for services during most school breaks. Our clinic-based services are typically available between 8am and 3pm. Our 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 for more details regarding scheduling and 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
Date of birth *
Date of birth
School Vacation of Interest *
Desired Service Location *
Please let us know about any scheduling questions or concerns you may have related to the available session times.