NEW CLIENT INFORMATION FORM

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Please complete and submit this form to begin the intake process for therapy. After receiving this form, we will be contacting you to answer questions and schedule your first appointment. We look forward to meeting your child!

Email *

Client Information

Child's Name *

Guardian's Name *

Child's Date of Birth *

Child's Age *

Name of School

Grade Level

Contact Phone Number *

Contact Email Address *

Mailing Address

Did someone refer you to Treehouse for services? If so, please provide the name of the individual, physician, therapist, school or business if applicable.

We are a private pay facility. We are not in network with any insurance company, including medicaid. We will provide a monthly statement for your records that contain procedure and diagnostic codes. It is the parent/guardian's responsibility to contact the insurance company to find out if out of network coverage is provided. If out of network coverage is provided, it will be the parent's responsibility to submit monthly receipts (which Treehouse provides to the parent) to his/her insurance and to seek reimbursement for therapy directly. Treehouse Pediatric Therapy does not accept payments from insurance companies. *

I understand that Treehouse Pediatric Therapy does not take insurance as a form of payment.

I understand that payment is due at the time of service.

Required

Therapy Requested

Please check which therapy/therapies you are seeking for your child: *

Feeding Therapy

Occupational Therapy

Speech-Language Therapy

Social Skills

Physical Therapy

Required

Please select which delivery model you prefer: *

In person therapy

Tele-therapy

Either in person or tele-therapy is fine - no preference

Required

Areas of Concern

Please provide detail regarding your child's diagnosis and/or areas of concern. *

Speech-Language Areas of Concern

Articulation/Speech Sound Production Skills

Expressive Language (difficulty using spoken language to express wants, needs, and ideas)

Receptive Language (difficulty uderstanding spoken language, following instructions)

Voice

Fluency/Stuttering

Social Skills/Pragmatics

Auditory Processing Disorder

Non-verbal/uses Augmentative Alternative Communication/Assistive Technology

Other:

Feeding Areas Of Concern

Difficulty chewing

Gagging/Vomiting

Reflux/GI Problems

Picky eater

Difficulty moving the food in mouth

Open mouth posture/drooling

Oral-motor weakness

History of swallowing difficulties

Weight/Growth

Other:

Occupational Therapy - Fine Motor Areas of Concern

Fine Motor (grasp, coloring, hand-writing, hand strength, mixed hand dominance)

Visual Perceptual Motor (cutting, puzzles, copying letters, copying designs)

Difficulty with dressing/fasteners (buttons, snaps, zippers, tying shoes)

Difficulty with self-feeding

Other:

Occupational Therapy - Gross Motor Areas of Concern

Clumsy/bumps into people or objects

Falls or trips frequently

Difficulty learning new motor skills (ex: jumping with two feet, riding a bike/trike, jumping jacks)

Fatigues easily/Difficulty keeping up with peers during play

Does not enjoy typical movement experiences such as swings, playground equipment, etc.

Stiff movements/tight muscles

Floppy/soft muscles

Other:

Occupational Therapy - Sensory Processing Areas of Concern

Difficulty processing auditory/sound information

Difficulty processing tactile/touch information

Difficulty processing vestibular/balance information

Difficulty processing proprioceptive/body awareness information

Difficulty processing visual information

Difficulty processing oral information

Difficulty processing olfactory information

Sensory seeking behaviors

Sensory avoiding behaviors

Other:

Behavioral/Social Emotional Areas of Concern

Attention difficulties

Low frustration tolerance

Frequent meltdowns/tantrums

Aggressive behaviors (hits, kicks, bites, etc.)

Difficulty reading social cues

Emotionally sensitive

ASD

Other:

Scheduling Considerations

What days of the week and specific times of the day (for ex: 8-10am, all morning, 3-5pm, all day) would your child be available for an initial evaluation/consultation? *

What days of the week and specific times of the day (for ex: 8-10am, all morning, 3-5pm, all day) would your child be available for on-going therapy if warranted?

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