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!
Email address *
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. *
Required
Therapy Requested
Please check which therapy/therapies you are seeking for your child: *
Required
Please select which delivery model you prefer: *
Required
Areas of Concern
Please provide detail regarding your child's diagnosis and/or areas of concern. *
Speech-Language Areas of Concern
Feeding Areas Of Concern
Occupational Therapy - Fine Motor Areas of Concern
Occupational Therapy - Gross Motor Areas of Concern
Occupational Therapy - Sensory Processing Areas of Concern
Behavioral/Social Emotional Areas of Concern
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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