Feeding Case History
This intake form provides me with the personal and clinical information necessary to effectively treat your child. It will streamline our evaluation process.

It contains 5 pages including demographics, family history, medical history, and the child's developmental history.

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Child's First Name *
Child's Last Name *
Child's Nickname
Child's Date of Birth *
MM
/
DD
/
YYYY
Child's Age *
Child's Sex *
Child's Diagnosis: (If unknown, write "n/a") *
When was your child given this diagnosis and by whom? Please write "n/a" if no diagnosis. *
Full Address (include city, state, zip) *
Phone #1 (preferred phone contact) and name: *
Phone #2 and name:
E-mail address *
Emergency Contact Name: *
Emergency Contact Relationship to Child: *
Emergency Contact Phone Number *
Child's Pediatrician *
Please list any other physicians involved in child's care.
Please submit photos of all 3 of the following to janine@expressivespeechandfeeding.com before your evaluation, if possible. View of the whole baby is important, while also being able to see their mouth.
How did you hear about Expressive Speech and Feeding? *
Person Completing the Form *
Relationship to the Child *
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