Consultation Request Form

First Name *

Last Name *

Preferred pronouns

Email *

Phone *

Do you live in Massachusetts? *

Yes
No

Due to licensing regulations, our clinicians can only provide therapy for people who live in Massachusetts. (Workshops are non-therapeutic and are open to anyone in the U.S.) If you do not live in Masschusetts and would still like to speak with us about other post adoption resources that might be helpful, we are still happy to connect with you as part of our nonprofit mission.

In which city and state to you live? *

What type of medical insurance do you have? *

Note: BPAR accepts most BlueCross BlueShield, Tufts Health Plan, Harvard Pilgrim Health Care, Allways Health Partners, and Optum policies, and we also accept out of pocket fees. Group therapy and group workshops are payable out of pocket only.

Clinical Services

Which of the following services are you interested in? (Check all that apply.)

Individual Therapy
Family Therapy
Couples Therapy
Group Therapy

Note: Specific Group Therapy choices will appear below if you "check" the Group Therapy option here.

Please answer the following:

Please use this space to tell us more about what kind of services or resources you are looking for.

Child Adoptee and Parent Therapy Groups

Which of the following child groups are you interested in? (Check all that apply.)

Kids Adoptee Group (age 8-10)
Tween Adoptee Group (age 11-12)
Teen Adoptee Group (age 13-15)
Teen Adoptee Group (age 16-18)

Which of the following parent groups are you interested in? (Check all that apply.)

Parents of Young Adoptees (age 4-7) Group
Parents of Kids (age 8-10) Adoptee Group
Parents of Tween (age 11-12) Adoptee Group
Parents of Teen (age 13-18) Adoptee Group
Parenting Group on Race
Single Parent Group

Please provide child's name and age (if applicable)

We will need this information if you are seeking therapy to support a child adoptee. This includes therapy for the child, therapy for the parents or family, and any therapeutic groups for children or parents.

Adult Adoptee Therapy Groups

Which of the following groups are you interested in? (Check all that apply.)

Adult Adoptee Workshops (non-therapeutic)

Which of the following groups are you interested in? (Check all that apply.) (copy)

Wellness Workshop Series
Writer's Workshop Series (to begin early 2022)

Because workshops are not therapeutic, they are open to attendees regardless of the state of residence.

Birth Parent Group

Check if you are interested in this group.

Birth Mom Group

Please tell us your age range.

18-30
31-40
41-59
60+

BPAR will need to complete an initial phone screen with you. If you have a preferred time for this call, please indicate your availability here.

If you would like a phone call from BPAR to discuss resources, please indicate your preferred time for this call here.

Would you like future updates? (Check all that apply.)

Yes, I'd like to join BPAR's general mailing list
I'd specifically like updates on BPAR groups as new groups develop
No thanks

Please add any requests for other groups below. Thank you!