Child Therapy Boston | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Date of birth

Gender

Child's Age

Child's Grade for 2025-2026 School Year

Child's School for 2025-2026 School Year

Child's Classroom/Teacher/Group/Homeroom for 2025-2026 School Year

Is Your Child a Former Client of Child Therapy Boston?

Yes No

Marital Status w/ Child's Other Parent:

Single, Married, Domestic Partner, Separated, Divorced, Widowed

Please provide the contact information for your child’s other parent if you are divorced and share legal custody.

Limited to 600 characters

Reason for care

Welcome! Please complete the form below and include any details that may be helpful for us to know when reviewing your child’s needs. If parents or guardians are separated or divorced, a completed screening form is required from each parent or guardian before services can begin. Child Therapy Boston is a private pay practice; we do not accept insurance, and full payment is due at the time of service. We do provide monthly statements that may be submitted to your insurance provider for potential out-of-network reimbursement. Please note that individual therapy is offered on a weekly basis only and we do not offer bi-weekly sessions. When a clinician becomes available, they will reach out via phone and email (please be sure to check your spam folder). To reserve your spot, we must hear back within 24 hours of initial contact. Once an intake is scheduled, all required paperwork must be submitted at least 48 hours in advance. We are unable to add your child to our waitlist unless this form is completed in full. If you have any questions, please feel free to reach out—we’re happy to help. Thank you! PLEASE ENTER THE DATE BELOW.

What are the reasons you’re seeking therapy for your child?

Feel free to share any concerns, goals, or areas where your child may need support.

Limited to 600 characters

Does your child have an IEP or 504 Plan?

If yes, feel free to share any relevant details you'd like us to know.

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Has your child had a neuropsychological evaluation?

If yes, please include the date and any relevant findings you’d like to share.

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Has your child received any diagnoses (mental health, developmental, or learning-related)?

If yes, please list them.

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Do you have any concerns about your child’s safety or the safety of others in relation to your child?

If yes, please provide more information.

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Does your child show any aggressive or physical behaviors toward themselves or others?

If yes, please describe the type of behavior, the setting (e.g., home, school), and who it is typically directed toward (e.g., parents, siblings, peers).

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What are your child’s strengths and interests?

We’d love to hear about what your child enjoys, excels at, or feels proud of.

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Billing & Payment

Payment method

How do you plan to pay?

Child Therapy Boston is a private pay therapy practice and does not accept health insurance. Payment is due at the time of service. While we do not bill insurance or communicate with insurance companies on your behalf, we provide monthly statements that may be submitted for out-of-network reimbursement, if applicable. Please review our current fees below: Individual & Family Services Intake Session: $225 Individual Therapy (50 minutes): $200 Family Therapy (50 minutes): $200 Parent Meeting / Feedback Session (50 minutes): $200 Parent Coaching (50 minutes): $200 Group & Intern Services Group Therapy (weekly, 50 minutes): $100 Intake with Graduate Intern: $100 Individual Therapy with Intern (50 minutes): $75 Insurance companies may require a diagnosis for out-of-network reimbursement. Please contact your insurance provider directly to confirm your benefits.

YES I HAVE READ AND UNDERSTAND CHILD THERAPY BOSTONS FEE STRUCTURE

Administrative

For Families with Shared Custody - If your child’s parents are divorced or separated and share custody, we require both parents to complete a screening form. Please be sure to provide contact information for your child’s other parent so we can reach out directly. We ask the following questions to help us ensure all necessary parties are included in the intake process. Thank you for your understanding and cooperation!

YES I UNDERSTAND CHILD THERAPY BOSTONS POLICIES REGARDING CONSENT AND DIVORCE

Are the child’s parents divorced and sharing legal custody?

Are either of the child’s parents currently involved in any open court cases related to divorce, custody, or child safety?

If you have not already done so, please provide the contact information for your child’s other parent if you are divorced and share legal custody. This allows us to send required paperwork for their completion. Please note, your child cannot be enrolled in services until this step is complete

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.