Intake Form

Thank you for contacting us to consult about your child’s tube-feeding needs. Please fill out the form below with as much detail as you can, and feel free to contact us with any questions at

Upon receipt of this intake form, our team of professionals will validate that it is safe to proceed with our consultation services and provide you further information around options available to you and your child.   

Parent Information
Parent/Guardian Name *
Parent/Guardian Name
Child Information
Child's Name *
Child's Name
Child's Date of Birth *
Child's Date of Birth
Feeding History
Feeding Tube Placement
Was a fundoplication performed?
Feeding Tube Use
Do you tube-feed during family meals? *
Does tube feeding seem comfortable? *
Does your child show any signs of distress? *
Does your child signal that they do not want to be tube fed? *
Does it seem like a procedure (check all that apply)? *
Oral Eating
Has your child been assessed for a safe swallow? *
Did your child eat orally at all before the tube was placed? *
Did the oral eating change over time until the tube was placed?
Does your child eat anything orally now?
How does your child eat?
How does your child act around the food?
Food Experience (if your child does not eat orally right now)
Does your child use a pacifier?
Will your child chew on toys, fingers, fabric, or other non-food items?
Does your child accept a spoon or bottle touching their mouth?
Therapy Experience (if any)
Has your child received any feeding therapy?
If yes, please select which one:
Has your child experienced any of the following?
Family Impact
We know that tube-feeding can be a “normal” experience or a highly stressful one. In this section, we are asking how tube-feeding is impacting your life, and any specific concerns that you have.
Do you feel a particular stress about: *

THANK YOU for taking the time to fill out this intake form. It will help us get to know you and your child much better before we speak in person. We will follow-up with you very shortly. We look forward to being a part of your journey!