Please complete the following form if you are seeking feeding therapy for your child from Therapy & Wellness Connection. Feeding Therapy Intake Child's Name(Required) First Last Does your child have a nickname? Child's Date of Birth(Required) Month Day Year Parent concern/reason for referral (ex: weight, oral motor skills, limited variety of foods eaten, etc.)(Required)Has your child received treatment in the past for feeding difficulties?(Required) Yes No If your child has received treatment for feeding difficulties, please indicate the name of the practice/facility: List any current medications your child is taking (please include vitamins, supplements, herbal remedies, and other over-the-counter medications):(Required)If none, write "N/A" for not applicable Does your child have any known allergies or restrictions (medical or food)?(Required) Yes No If your child does have known allergies/restrictions, please describe:Gastrointestinal history concerns (check all that apply):(Required) Reflux/GERD Spitting up Arching Failure to thrive Burping Coughing Desire to eat, then refuses Slow gastric emptying Vomting Drooling Chronic diarrhea Constipation Dehydration General discomfort when eating Other None of the above If you replied "other" to gastrointestinal history concerns, please indicate what those are here: Has your child had any of the following surgical procedures (check all that apply):(Required) Adenoids Tonsils Frenectomy/tongue-tie release GI (ex: intestines, colon, stomach) Head (ex: jay, cleft palate, lips, etc.) Neck (tracheotomy) Other None of the above If your child has had any of the above listed surgeries, please describe.Where does your child usually sit during mealtimes? (Check all that apply):(Required) At table Booster seat Child stands On caregivers' lap Held by caregiver Child wanders/grazes Infant seat/highchair In front of TV Other If you answered "other" to where your child sits during mealtimes, please describe: How does your child feed?(Required) Self-feeds Fed by caregiver Other If you answered "other" to the question about how your child feeds, please describe: What mealtime behaviors does your child exhibit? (Check all that apply)(Required) Cries or screams Throws food Pushes food away Clenches lips Makes a mess Eats too fast Eats too slowly Pockets food in cheeks Shuts down or withdraws Plays with food Refuses to swallow Turns away from food Spits out food Picky eater Vomits Eats non-foods Other None of the above If you answered "other" to mealtime behaviors your child exhibits, please explain: What feeding behaviors does your child exhibit?(Required) Choking Drooling Hypersensitivity Hyposensitivity Sweating Chewing Coughing Overstuffs mouth Teeth grinding Difficulty biting Gagging Vomiting History of aspiration Other None of the above If you answered "other" to feeding behaviors your child exhibits, please describe: What feeding interventions have caregivers or medical specialists tried with your child before? (Check all that apply):(Required) Feeding only when child requests Feeding only what child requests Coaxing or verbal persuasion Forcing food or meals, despite child refusal Alternative nutrition (ex: NG, PEG tube) Allowing child to drink more than eat High calorie supplements, formula Punitive measures or negative consequences Other None of the above If you answered "other" to feeding interventions, please describe: Describe any food selectivity or preferences your child demonstrates (i.e., taste, temperature, texture, etc.)(Required)Please tell us anything else you think may be important for us to know about your child's feeding:(Required)What feeding goals do you have in mind for your child? (ex: increasing diet variety, improving intake, facilitating chewing/swallowing, etc.)(Required)If you have additional clinical or educational documentation pertaining to your child's diagnosis, treatment, or education that would be relevant for feeding therapy and that you did NOT already upload on the main Intake Form for All New Patients, please upload here. Drop files here or Select files Max. file size: 195 MB. Tell us what days, times, and location would be ideal for Feeding Therapy. (Ex: Anytime Monday-Thursday, 8a-3p, in-clinic/at home, etc.)*(Required)While we cannot guarantee our availability will match your desired schedule exactly, we'll do our best! Parent Name(Required) Parent Phone Number(Required)Parent Email Address(Required) What is your preferred method of contact?(Required) Phone Call Text Message Email How did you hear about us?(Required) Online search Social media Brochure, flier, business card, or other printed media Recommended by friend or family member Referred by physician or other healthcare provider Online ad Other If you answered "other" to the previous question, please describe: Parent/Guardian Electronic Signature(Required) First Last By providing this electronic signature, I hereby affirm I am the parent/guardian of the aforementioned child, for whom I am legally authorized to make medical decisions. I agree to each of the above conditions as indicated, and certify all information contained in this form is complete and accurate to the best of my knowledge. I understand that an electronic signature is the legal equivalent of my manual/handwritten signature, and I am agreeing to all terms and conditions as indicated in this form.Today's Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 29762Δ
