Feeding Therapy Screening Form
Email address *
Phone number
Your answer
Child's name
Your answer
Child's date of birth
Your answer
Name of person completing this form
Your answer
Does your child exhibit any of the following?
Does your child consistently eat at least 3:
Do any of the following behaviors occur when you give your child new or less preferred foods?
Has a physician or speech therapist indicated that your child should not be fed by mouth?
Does your child have a history of any of the items below?
Does your child receive tube feedings?
Is your child followed by any of the following service providers?
Please list any diet restrictions that your child may have.
Your answer
Who will be involved in caregiver training appointments?
How did you hear about us?
Your answer
Is there anything else that you would like us to know about your child's mealtime behavior?
Your answer
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