2023 SLP Assessment Form

Does your child struggle at mealtimes? Do they have habits of picky eating and problem feeding that cause you worry, frustration, and confusion? Your child may benefit from feeding therapy, provided by a licensed speech language pathologist. Complete this short 10 question quiz to find out if you qualify for an evaluation!

Please select “Yes” or “No” to indicate if your child exhibits the behaviors described in the following statements:

Your child demonstrates meltdown behaviors at the dining table, such as hitting, kicking, yelling, throwing food, hiding, refusing food, repeatedly attempting to leave the table, tantrums, etc.

Your child frequently gags, vomits, excessively coughs, arches their back, or ‘chokes’ during meals.

Mealtimes for your child last more than 30 minutes on a regular basis.

Your child struggles with basic feeding skills including difficulty with straw or cup drinking, difficulty holding/manipulating silverware, difficulty grasping foods, difficulty bringing foods to mouth.

Your child avoids certain food groups/textures and will demonstrate an aversion when exposed to those foods (e.g., gagging, sneezing, cringing, wiping hands, looking away/covering face, etc.).

The way food is presented matters a lot to your child, and they may become very upset at the sight of certain foods, if foods are touching, or if the food/drink is served from the “wrong” dish.

Your child wants to eat the same foods, prepared the same way, every day until suddenly they can no longer stand that food.

Your child barely eats meals, but frequently asks for snacks.

Your child struggles greatly to chew and swallow certain textures of foods.

Your child struggles to recognize their body’s cues about whether they are hungry or full.

If you answered "Yes" to 4 or more questions, your child would benefit from a feeding evaluation with a professional at Behavioral Health Clinic. To schedule, please call our office at 855-607-8BHC (8242). To learn more, please visit our website at wibehavioralhealth.com.