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 *
Your answer
Guardian's Name *
Your answer
Child's Date of Birth *
Your answer
Child's Age *
Your answer
Current Grade Level/Name of School
Your answer
Contact Phone Number *
Your answer
Contact Email Address *
Your answer
Mailing Address
Your answer
Did someone refer you to Treehouse for services? If so, please provide the name of the individual, physician, therapist, school or business if applicable.
Your answer
We are a private pay facility. We will provide you with monthly statements for your records should your insurance cover out-of-network providers and you want to submit to your insurance for reimbursement. *
Required
Therapy Requested
Please check which therapy/therapies you are seeking for your child: *
Required
Areas of Concern
Please provide detail regarding your child's diagnosis and/or areas of concern. *
Your answer
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 and times would your child be available for an initial evaluation/consult and ongoing therapy if needed. *
Your answer
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