Occupational Therapy Intake Form
Thank you so much for reaching out to Creating Connections regarding potential services and support through our practice. We are excited about the possibility of working with your child and family!

 Please fill out this quick intake form to provide us more information on your child and the areas of support you are looking for. Once you fill out this form you will receive an email from us and we will schedule a call with you in 2-3 weeks. 

One thing to note is that we only accept BCBS and Mass General Brigham Health insurance, however, we do have very competitive private pay prices ($99 per session). 
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Email *
Child's Name (First/Last):
Child's DOB:
MM
/
DD
/
YYYY
Parent/Caregiver Name (Contact 1):
Parent/Caregiver Phone # (Contact 1):
Parent/Caregiver Name (Contact 2):
Parent/Caregiver Phone Number # (Contact 2):
Street Address: 
City/Town:
Health Insurance Provider: 
Current Diagnosis, if any please list below:
Current occupational therapy concerns:
Availability for treatment sessions:
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Preference of location for OT session:
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Who referred you to Creating Connections ? 
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