Parent/Guardian Name
*
First Name
Last Name
Email
*
example@example.com
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
/
Month
/
Day
Year
Date
What is your child's current eating schedule (at what times during the day)?
What foods does your child currently accept? If you're not worried about food variety, simply say "family foods" or "no concerns"
What drinks does your child currently accept?
Does your child have difficulty growing or gaining weight? Please describe.
Does your child have any food allergies?
Does your child have behaviors or responses that would interfere with mealtimes? Please describe.
Describe your stress level regarding your child's eating.
What helps make that stress better?
What makes it worse?
What are your goals for the Happy Eaters program? Please be as specific as you can.
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