We’re excited you’re considering Treeline for your child’s physical therapy services. Because pediatric physical therapy requires additional medical documentation, we want to help make the process as smooth and clear as possible for families.

Before Completing This Form
📞 Optional: Schedule an Information Call
If you would like to learn more about our services, ask questions, or discuss whether Treeline may be a good fit for your child, we encourage you to schedule a brief call with our administrative team before completing this form.

https://calendar.app.google/dN4JtFvThNUySwhY6

Please Have the Following Ready Before Completing This Form
You will need ONE of the following:

Option 1: A physician order/prescription for a physical therapy evaluation
Option 2: A current physical therapy evaluation (within the last 6 months) with a signed plan of care

Additional Information You Will Need

Physician name
Physician fax number
PDF copy of required documents

Please note: PDF files are required. Photos/screenshots cannot be accepted. Incomplete submissions may delay scheduling. Once your form and required documentation are reviewed, our team will contact you regarding next steps.

Today's Date

Date

Therapeutic Approach

Treeline aims to be a neurodivergent affirming practice. We use identify-affirming language (i.e. autistic child) and not person-first language (child with autism) because we believe being neurodivergent is a part of their identity. Neurodivergency is a different way of thinking, learning, and doing.
Our therapists use cues of safety, sensory supports, and relationship-based interventions to support children in sessions. We are not a setting that subscribes to compliance-based ABA principles and strategies.
We are a play-based setting that is motivated to work with your child's strengths and in their unique areas of interests.
Treeline values strong parent partnerships, regular communication, and therapy that is focused on very functional and meaningful objectives that the parent helps to write. Parents are expected to be active partners in the therapy process. Treeline is not the setting to simply drop your child off for a session once a week and that's it. We are your partners in this journey to help your child thrive.
We say yes to the mess ... every time (inside and outside). At Treeline, your child will leave therapy sessions a little (or a lot) dirty (or wet), sometimes stinky, and sometimes a little tired. We will not ask your child to NOT play in the mud, water, paint, etc. if they are interested, instead, we WILL play in it with them!

We are NOT the right setting for every child or every family. When you select Treeline to help your child, you understand the above is the Treeline therapeutic approach and you are ready for your child to grow and learn and thrive under these principles.

I have read and agree with the Treeline Therapeutic approach (above).

Treeline's indoor space is a residential turned commercial property with lots of charm. However it is not ADA compliant and the indoor space is only accessed up 4-6 stairs.

All billing is completed at the end of the month for services rendered. I understand that Treeline Enrichment does not work directly with any insurance company. Treeline is a direct provider for the Family Empowerment Scholarship, accepts Private Pay, and will provide a Superbill to a family upon request.

Your insurance plan must have out-of-network benefits in order for you to be reimbursed for services provided by Treeline Enrichment, as we are not part of any insurance network. It is very important that you check with your insurance provider before starting services to clarify what services are covered, how they are covered, and how they are reimbursed.

Child's Full Name

First NameLast Name

Child's Gender

Child's Birthdate

Date

Parent / Guardian Name

First NameLast Name

Parent / Guardian Phone Number

Area CodePhone Number

Parent / Guardian Email

example@example.com

Where did you hear about Treeline Therapy?

Why are you seeking physical therapy services for your child?

Describe any therapy services that your child is currently receiving or has received in the past.

Physical therapy service availability is very limited

Please select all availability that applies to your family:

Do you have a current (within the last 6 months) PT evaluation from a Florida physical therapist that recommends physical therapy services?

Please upload a PDF copy of a current physician's ORDER for a physical therapy evaluation for your child. You cannot submit this form without this order attached.

Browse Files

If you have a current PT evaluation from a Florida physical therapist that recommends services and includes a signed Plan of Care, please upload the evaluation now.

Browse Files

Physician

Physician Practice

Physician Phone

Area CodePhone Number

Physician Fax

Area CodePhone Number

Behavior Policy

Our therapists use cues of safety, sensory supports, and relationship-based interventions to help children handle big emotions and behaviors.

If a child has disruptive behaviors that impact the safety of themselves or the therapists, we will immediately collaborate with the parents to discuss relationship-based strategies to further support safety in sessions. Should it be decided by the therapist and parent that this location is not a good fit for the child, services will be terminated.

Share comments, questions, or concerns that you have about your child's participation.

Would you like to be added to our email list to receive therapy tips and announcement emails from Treeline?

I have filled out this form completely and reviewed it for accuracy.

If you have not completed an informational call with the Treeline administrator and would like to see if Treeline is a good match for your family and child, please schedule that call upon sumitting this form.

Getting Started with Pediatric PHYSICAL Therapy

Physical therapy service availability is very limited

Behavior Policy