- Treehouse Therapy CenterTreehouse Therapy Center

Child Information

Child's First Name *

Child's Last Name *

Date of Birth *

Current Age *

Gender

Current Diagnosis

Autism Spectrum Disorder (ASD) ADHD Developmental Delay Intellectual Disability Other No formal diagnosis yet

Diagnosis Details

Parent/Guardian Information

Parent/Guardian First Name *

Parent/Guardian Last Name *

Email Address *

Phone Number *

Relationship to Child *

Home Address *

City *

State *

ZIP Code *

Insurance Information

Primary Insurance Company *

Member ID

Policy Holder Name

Policy Holder Date of Birth

I authorize Treehouse Therapy Center to contact my insurance company to verify benefits and coverage for ABA therapy services.

Services Requested

Which services are you interested in? (Check all that apply) *

In-Home ABA Therapy

One-on-one therapy in your home environment

Community-Based ABA

Therapy in community settings (parks, stores, etc.)

School Support Services

Collaboration with school teams and IEP support

Parent Training

Learn ABA strategies to support your child

Behavioral Assessment

Comprehensive evaluation of your child's needs

Early Intervention (Ages 0-3)

Specialized services for very young children

Preferred Start Date

How urgent is your need for services?

Child's Current Needs & Goals

What are your child's current challenges or areas of concern? *

What are your main goals for therapy? *

Is your child currently receiving any other services?

Has your child received ABA therapy before?

If yes, please provide details about previous ABA services

Additional Information

How did you hear about Treehouse Therapy Center?

Is there anything else you'd like us to know about your child or family?

Preferred contact method for follow-up

Phone call Email Text message Either phone or email

Best time to contact you

Consent & Authorization

Information Accuracy *
I certify that all information provided in this enrollment form is accurate and complete to the best of my knowledge.

Contact Authorization *
I authorize Treehouse Therapy Center to contact me via phone, email, or text message regarding this enrollment application and future services.

Records Release (Optional)
I authorize Treehouse Therapy Center to request and review relevant medical, educational, and therapeutic records to better serve my child.

Start Your ABA Therapy Journey

🏠 In-Home Services

🏫 School Support

👨‍👩‍👧‍👦 Family Training

Your Enrollment Process

Complete Intake Form

Initial Consultation

Assessment & Planning

Begin Services

Enrollment Application