Contact Information Parent/Guardian Name(s): * Child's Name: Child's Date of Birth MM DD YYYY Email Address: Phone Number: Country (###) ### #### Address: Address 1 Address 2 City State/Province Zip/Postal Code Country Medical and Developmental History Has your child been diagnosed with any medical conditions? (e.g., GERD, ARFID, autism, etc.) Yes No If yes, please specify: Does your child have any known allergies or dietary restrictions? Yes No If yes, please list: Was your child born prematurely or experienced complications at birth? Yes No If yes, please describe: Has your child had any surgical procedures related to feeding/swallowing? Yes No If yes, please describe: Feeding History What is your child's current feeding method? Oral feeding G-tube feeding NG-tube feeding Combination Describe your child's current diet (e.g., types of foods, textures, liquids): . Does your child experience any of the following during meals? Gagging Choking Vomiting Refusing food Coughing Difficulty chewing/swallowing Other: Does your child have any oral motor or sensory challenges (e.g., avoiding certain textures, mouthing objects, etc.)? Yes No If yes, please explain: Current Challenges What are the main feeding challenges you are concerned about? (Check all that apply) Oral aversion Food refusal Limited food variety (picky eating) Poor weight gain/growth Difficulty transitioning to solids Prolonged mealtimes Behavioral issues during meals Other: How long have these challenges been present? Previous Interventions Has your child received any feeding therapy in the past? Yes No If yes, please provide details (e.g., type of therapy, duration, outcomes): Is your child currently working with any other therapists or medical professionals? Yes No If yes, please list them: Family and Environmental Information Describe your typical mealtime environment (e.g., distractions, routines, seating): How many meals/snacks does your child eat daily? Who is typically present during mealtimes? Goals and Expectations What are your primary goals for the feeding intensive program? What outcomes would you consider successful after completing the program? Are you open to parent coaching and participating in therapy sessions? Yes No Scheduling and Logistics Do you have any preferred days or times for sessions? Are there any additional concerns or questions you’d like addressed? Thank you!
