Food Explorers Interest Form
Mitchell's Place is offering a group for children in 3rd - 5th grade who struggle with very picky eating. This group will involve teaching child about food using a "food scientist" approach, introducing new foods in a safe and fun environment, and teaching parents how to use these strategies at home to address picky eating. This group will take place on Wednesday from 3:30-4:15PM, September 10 to October 15, 2025. It will be co-led by a speech-language pathologist and an occupational therapist. If you are interested in participating, please submit this form and a provider will be in contact about the next steps.
Participant Name
*
First Name
Last Name
Participant Date of Birth
-
Month
-
Day
Year
Date
Parent/Caregiver Name
First Name
Last Name
Contact Number
*
E-mail
*
example@example.com
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Briefly describe your child's feeding difficulties
*
Please list any feeding allergies your child has (if any)
Please rate your child's willingness to eat the following foods:
Never Eats
Sometimes Eats
Always Eats
Milk
Yogurt
Bacon
Eggs
Sausage
Chicken Nuggets
Deli Meat
Hot dogs
Peanut Butter
Nut Butters
Grilled/Baked Chicken
Pork
Steak
Fish
Shrimp
Cheese
Apples
Watermelon
Strawberry
Oranges
Grapes
Bananas
Pineapple
Avocado
Blueberry
Raspberries
Blackberries
Cucumber
Broccoli
Carrots
Corn
Potatoes
Green Beans
Peas
Peppers
Sweet Potatoes
Chips
Cookies
Crackers
Bread
Oatmeal
Pancakes
Waffles
Rice
Pasta Noodles
Tortillas
French Fries
Pizza
Mac n Cheese
Popcorn
Candy
Chocolate
Granola Bars
Cereal
Pretzel
Veggie Straws
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Describe your child's communication
*
Complex sentences (e.g., "Can we go outside and play?")
Short phrases/simple sentences (e.g., "I want milk," "more chips")
Single words (e.g., "milk," "more")
Other
Select which, if any, of these behaviors your child exhibits when upset
*
Yells, cries, or screams
Hits others
Hits self
Refuses to follow directions
Argues with adults
Runs away/tries to leave
NONE
Other
How often do the above behaviors occur?
Rarely (less than once per week)
1
2
3
4
5
6
7
8
9
Frequently (multiple times per day)
10
1 is Rarely (less than once per week), 10 is Frequently (multiple times per day)
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