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613-277-3155
info@tubefreeliving.com
Intake Form
Thank you for contacting us to consult about your child’s tube-feeding needs. Please fill out the form below with as much detail as you can, and feel free to contact us with any questions at info@tubefreeliving.com. Upon receipt of this intake form, our team of professionals will validate that it is safe to proceed with our consultation services and provide you further information around options available to you and your child. We cannot approve ANY weaning plan without evidence of a safe swallow as observed by a therapist, physician, or radiological exam (swallow study). Please be sure to include this information in the intake below.
Parent Information
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Email
*
Best Time to Contact
Phone
*
Father's Height
Mother's Height
Child Information
Child's Name
*
First
Last
Child's Date of Birth
*
Date Format: MM slash DD slash YYYY
Child's Gender
Male
Female
Please upload a copy of you child's growth curve(s)
Accepted file types: jpg, pdf, png.
PDF, JPG, or PNG. If there are issues with upload, please email info@tubefreeliving.com
Current known allergies
Current medications
Feeding History
How did you initially feed your baby?
What made you feel there were eating concerns?
What medical conditions, if any, was your child diagnosed with?
Feeding Tube Placement
What was the age of your child when the initial tube was placed?
What kind of tube was it?
Please explain why the tube was required.
What type of tube is being used now?
Relevant surgeries
Feeding Tube Use
What is your child's current tube feeding regime?
Does your child have any difficulties with tube feed tolerance? Please describe.
Oral Eating
Has your child's swallow been assessed?
Yes
No
If yes, what study was performed?
If yes, when was it performed?
What where the results?
What recommendations were you provided with following the swallow assessment?
Did your child eat orally before the tube was placed?
Yes
No
Describe your child's acceptance and experience with eating prior to the tube placement.
If your child ate before the tube, how did his/her eating change after the tube?
Does your child eat anything orally now?
Yes
No
If yes, please list food, timing and quantity for a 24 hour period.
Do you use rewards, distractions to encourage eating?
What are your child’s preferred foods or drinks?
Is there a texture your child prefers?
Is there a texture your child finds difficult?
Does your child join you for mealtime?
Therapy Experience (if any)
Has your child received any feeding therapy?
Yes
No
If yes, please select which one:
OT
RD
SLP
Other
What did you find most helpful?
What did you find least helpful?
How is your child's overall development?
Family Impact
We know that tube-feeding can be a “normal” experience or a highly stressful one. In this section, we are asking how tube-feeding is impacting your life, and any specific concerns that you have.
What are your goals for your child in the area of feeding?
What do you hope to gain from this program?
Is there anything else you would like to share with us about your child?
How did you hear about Tube Free Living?
*
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