NEW CLIENT INFORMATION FORM
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!
Child's Date of Birth
Name of School
Contact Phone Number
Contact Email 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.
Please check which therapy/therapies you are seeking for your child:
PEERS Social Skills Group
Please select which delivery model you prefer:
In person therapy
Either in person or tele-therapy is fine - no preference
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)
Auditory Processing Disorder
Non-verbal/uses Augmentative Alternative Communication/Assistive Technology
Feeding Areas Of Concern
Difficulty moving the food in mouth
Open mouth posture/drooling
History of swallowing difficulties
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
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
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
Behavioral/Social Emotional Areas of Concern
Low frustration tolerance
Aggressive behaviors (hits, kicks, bites, etc.)
Difficulty reading social cues
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?
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service