Child Therapy Boston | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Date of birth

Gender

State

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Child's Age

Child's Grade for 2026-2027 School Year

Child's School for 2026-2027 School Year

Child's Classroom/Teacher/Group/Homeroom for 2026-2027 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.

Please note: If parents/guardians are separated or divorced, each parent/guardian must complete a screening form before services can begin. If one parent/guardian has 100% legal custody, please email a copy of the divorce decree, custody agreement, or other documentation confirming custody to connect@childtherapyinboston.com

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Child's preferred pronouns

Reason for care

Welcome to Child Therapy Boston! Please complete the form below and include any information that may be helpful as we review your child’s needs.

EXISTING CLIENTS & SIBLINGS: If you or your child has previously been seen by Child Therapy Boston, or if a sibling is already in our system, DO NOT SUBMIT THIS FORM. You will receive an error message. Please contact us at connect@childtherapyinboston.com and we will assist you. CUSTODY: If parents/guardians are separated or divorced, each parent/guardian must complete a screening form before services can begin. If one parent/guardian has 100% legal custody, please email a copy of the divorce decree, custody agreement, or other documentation confirming custody to connect@childtherapyinboston.com. PAYMENT & INSURANCE: Child Therapy Boston is a private-pay practice and does not accept insurance. Payment is due at the time of service. Monthly statements are provided for families who wish to seek potential out-of-network reimbursement. THERAPY FREQUENCY: Individual therapy is offered weekly only. We do not offer bi-weekly sessions. NEXT STEPS: When a clinician becomes available, they will contact you by phone and email. Please check your spam/junk folder. You must respond within 24 hours to reserve an available spot. Once an intake is scheduled, all required paperwork must be completed at least 48 hours in advance. WAITLIST: Your child cannot be added to our waitlist until this form is completed in full. Questions? Contact us at connect@childtherapyinboston.com. PLEASE ENTER TODAY’S DATE BELOW.

What services are you interested in?

Individual Therapy Group Therapy Parent Coaching & Support Individual Therapy for Parents Other

What are the reasons you’re seeking therapy?

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

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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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If you are seeking parent services ONLY, please enter your child’s full name below.

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Is there anything else you would like us to know?

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Administrative

How did you hear about Child Therapy Boston?

Enter how you were referred to our services

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

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Please ensure you click the "send message" button below to complete your screening form. Once you submit this form, our adminstrative team will review and follow-up with you as soon as possible. If you have any questions or any difficulties completing the form, please feel free to contact us directly (connect@childtherapyinboston.com | 781-400-2641). Thank you and we look forward to connecting soon!

I understand

Billing & Payment

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. Insurance companies may require a diagnosis for out-of-network reimbursement. Please contact your insurance provider directly to confirm your benefits. Our standard session length is 50 minutes for all services.

I HAVE READ AND UNDERSTAND CHILD THERAPY BOSTONS FEE STRUCTURE

Please review our current fees below. Our standard session length is 50 minutes for all services. Included are the CPT codes you may provide to your insurance to check if you have out of network coverage for reimbursement:

Intake Session: $225 (CPT Code 90791) Individual Therapy Session: $200 (CPT Code 90834) Family Therapy Session: $200 (CPT Code 90846 or 90847) Parent Meeting and/or Feedback Session: $200 (CPT Code 90846) Parent Coaching Session: $200 (CPT 90847) Group Therapy Session: $110 (CPT Code 90853) Intake Session with Graduate Intern: $100 (CPT codes not applicable for interns) Individual Therapy Session with Graduate Intern: $75 (CPT codes not applicable for interns)

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.