Get Started
Please fill out the following information to get your child started with Treehouse Therapies. After you have completed this form please contact your child's pediatrician to send a referral to us, if you haven't done so already. You will receive a phone call or email the next business day to complete the set up.
Email address *
Patient Name (First Last) *
Gender *
Patient DOB *
MM
/
DD
/
YYYY
Parent Name (First Last) *
Other Parent Name (First Last)
Primary Phone Number *
Secondary Phone Number
Address *
Street, City, State, Zip
Preferred Method of Communication *
Required
Primary Insurance Company *
ID# *
Secondary Insurance Company
ID#
Pediatrician's Name *
Pediatrician's Phone Number (if known)
Primary Concerns or Diagnosis (if known) *
What would you like your child seen for? *
Required
Preferred Day and Time
Morning (9am-12pm)
Afternoon (12pm-3pm)
Evening (3pm-6pm)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Any Additional Information?
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This form was created inside of Treehouse Therapies Associates.