Enroll in our Food Explorers Program

Picky Eating Group Therapy Intake Form

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Food Explorers Program Registration Form

For picky eaters.

Child's Information:

Child's Name(Required)

First Last

Preferred Name (if different):

Age

Date of Birth

MM slash DD slash YYYY

Grade (if applicable)

Gender:

School Attending (if applicable):

Are you a current STP patient?

Yes

How did you hear about us

Parent/Guardian Information:

Name

First Last

Relationship to Child:

Contact Number (Primary):

Contact Number (Secondary):

Email Address:(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact Information:

Emergency Contact Full Name:

First Last

Relationship to Child:

Contact Number (Primary):

Contact Number (Secondary):

Health Information:

Does your child have any allergies? If yes, please specify:

Environmental allergies:

Is your child currently taking any medications? If yes, please specify:

Name of medication and dosage:

Are there any medical conditions or special needs that we should be aware of? If yes, please specify:

Picky Eating Information:

How would you describe your child's eating habits? (check all that apply)

Selective about certain foods

Refuses entire food groups (e.g., vegetables, meats)

Difficulty trying new foods

Ritualistic or repetitive eating behaviors

Other

When did you first notice your child's picky eating behaviors? Was there any event or change that seemed to trigger these behaviors?

How does your child's picky eating affect mealtime routines and family dynamics? (e.g., arguments, stress, limited food options)

Have you sought any previous interventions or treatments for your child's picky eating? If yes, please provide details:

What are your goals or expectations for your child's participation in the picky eating group therapy program?

Feeding History:

These questions can provide valuable insights into the child's feeding history, preferences, and challenges, helping the therapy team develop a comprehensive understanding of the child's needs and tailor interventions accordingly.

What was your child's feeding experience like during infancy and early childhood? (e.g., breastfed, formula-fed, introduction to solid foods)

Did your child experience any feeding difficulties or challenges during infancy? (e.g., difficulty latching, reflux, aversion to certain textures)

Describe your child's typical mealtime behaviors and routines. (e.g., frequency of meals/snacks, preferred eating environment, distractions during meals)

Has your child experienced any traumatic or negative experiences related to food or mealtimes? (e.g., choking incidents, force-feeding, pressure to eat)

Are there any family or cultural factors that influence your child's food preferences or eating habits? (e.g., cultural dietary restrictions, family meal traditions)

How do you approach feeding your child? (e.g., meal planning, offering choices, setting mealtime rules)

Have there been any significant changes in your child's eating habits or appetite recently? (e.g., changes in appetite, weight loss/gain, mealtime refusal)

Does your child have any sensory sensitivities or aversions that may impact their eating? (e.g., sensitivity to certain textures, aversion to strong flavors)

What strategies have you tried at home to address your child's picky eating? (e.g., offering rewards, using food as a bribe, implementing mealtime rules)

How does your child's picky eating impact their social interactions or participation in activities outside of home? (e.g., reluctance to attend social events involving food, challenges eating at restaurants or school)

Consent

I consent to my child's participation in the Literacy Camp Program.

I understand that the camp organizers will take all necessary precautions to ensure the safety and well-being of my child during their participation in the camp activities. Thank you for completing the intake form. We appreciate your attention to detail and look forward to providing your child with a rewarding experience at our Literacy Camp!

Parent/Guardian Name:

First Last

Date

MM slash DD slash YYYY

Untitled

Picky Eating Group Therapy Intake Form

Food Explorers Program Registration Form

Child's Information:

Parent/Guardian Information:

Emergency Contact Information:

Health Information:

Picky Eating Information:

Feeding History:

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