Happy Eaters Intake Form

Thank you for contacting us to consult about your child’s 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 info@gieaters.com.

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 Gender *
Child's Date of Birth *
Child's Date of Birth
Feeding History
Oral Eating
Has your child been assessed for a safe swallow? *
Has your child ever been tube fed? If so, when was the last time? *
How does your child eat?
How does your child act around the food?
Therapy Experience (if any)
Has your child received any feeding therapy?
If yes, please select which one:
Family Impact

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!