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Thrive Pediatrics
Home
What We Do
Intake Assessment
Intake Form - English
Intake Form - Spanish
General Movement (GMA) Info
Family Resources
Shop Thrive Swag
THRIVE Coloring Pages
GIft Guides
Trick-or-Treat Cards
Groups
Thriving Eaters
Rental Space
Our Team
Physical Therapists
Occupational Therapists
Speech-Language Pathologists & Assistants
Infant Teachers
Office & Compass Intake Teams
Work with us
Parent/Guardian Name
*
First Name
Last Name
Phone
*
(###)
###
####
Email
*
Child's Name
*
First Name
Last Name
Child's Date of Birth
MM
DD
YYYY
Does your child have a diagnosis?
*
Yes
No
If yes, please list:
Is your child already receiving Inland Regional Center services (such as therapy or specialized instruction)?
Yes
No
If yes, who is your IRC case worker?
Does your child have any food allergies or intolerances? If so, please list them:
*
Give a brief description of your child’s feeding history (how was introducing solids, bottle and/or breastfeeding? Any reflux? Concerns with weight gain/growth chart? Previous feeding tubes? Difficulty transitioning to solid foods?)
*
Is your child safe with eating solid foods? (no frequent gagging, coughing, or choking episodes with foods or liquids)
*
Yes
No
If no, please explain:
What is your child’s current food list (foods they eat 80% of the time or more)? Please be specific, listing types or brands of foods (ex: chicken nuggets, shredded chicken breast, etc.). Write NONE if your child does not eat any foods within that food group.
Fruits:
*
Vegetables:
*
Proteins:
*
Carbohydrates/Starches:
*
Liquids:
*
How long does your child sit for around mealtimes?
*
3-5 minutes
5-10 minutes
The whole meal
They don’t sit!
Thank you! We will be in touch shortly with more info!