New Client Registration

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Please complete and submit this form to begin the intake process for therapy. After receiving this form, we will be contacting you to answer questions and schedule your first appointment. We look forward to meeting your child!

Email *

Form Completion Date: *

YYYY

Child's Name and Parent/Guardian Name *

Child's Date of Birth *

YYYY

Contact Phone Number and Mailing Address *

Did someone refer you to Mealtime Connection? If so, please provide the name of the person or place below. *

We are a private pay clinic. We are not in network with any insurance company, including Medicaid. We will provide a monthly statement for your records that contain procedure and diagnostic codes upon request. It is the parent/guardian's responsibility to contact the insurance company to find out if out of network coverage is provided. If out of network coverage is provided, it will be the parent/guardian's responsibility to submit monthly receipts (provided by Mealtime Connection) to his/her insurance and to seek reimbursement for therapy directly. Mealtime Connection does not accept payments from insurance companies. (Both boxes must be checked prior to any therapy appointment) *

I understand Mealtime Connection does not accept insurance as a form of payment.

I understand payment is due at time of service.

Required

What is your child's birth history AND Primary diagnosis prior to coming to Mealtime Connection? *

What is your child's past medical history? (Include any other pertinent information in this section)

Areas of Concern; Please select all that apply *

Difficulty Chewing

Gagging/Vomiting

Reflux/GI Concerns

Picky Eater

Difficulty moving food in the mouth

Open mouth posture/Drooling

Oral-motor weakness

History of swallowing difficulties

Adequate weight/growth

Speech-language difficulty

Tongue-Tie diagnosis

Other:

Required

Please use this space to describe in greater detail the concern(s) selected above:

What are your overall goals for your child to achieve?

Mealtime Connection is an "Appointment Only" clinic. This means our hours and days of operation sometimes vary. Please contact the office upon completion of this registration by emailing KFerguson@MealtimeConnection.com or calling 804-449-7227 and someone will be happy to assist you with scheduling the next available date and time for your child. Please indicate your preferred method of communication below. *

Phone

Text (Additional Fees may apply depending on your service or carrier)

Required

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