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Steps to Feeding Success

Steps to Feeding Success Contact Form

Please use this form to make a referral or to contact us with an enquiry.

Information about your child

Child’s Full Name*

Child’s Date of birth* Please use dd/mm/yyyy format

Address*

Gender

NHS Number (if known)

Registered GP Practice

Telephone Number*

Would you like us to inform your child’s GP on the care they receive from us?*

Would you like your care to be included within your child’s shared NHS record?*

Information about the person completing the form

Name of person completing this form*

Your relationship to the child*

Telephone number

Email address*

Preferred contact method

Please confirm you are the child’s legal guardian / parent*

Service Criteria Confirmation

Our referral guidelines provide an overview of whether our service may be of benefit to your child, please tick to confirm that you have considered each of the following statements:

*My child does not have any suspected or diagnosed medical conditions listed within the referral guidelines, this includes feeding difficulties primarily related to medical or physical conditions (e.g. reflux, oral-motor dysfunction not relation to sensory processing). My child does not have a primary diagnosis of an eating disorder (e.g. anorexia, bulimia, ARFID).

*My child will be able to sit and engage in play-based activities as part of their therapy.

*My child has two or more difficulties which are impacted by their eating e.g. response to different textures, Limited and restrictive food choices, difficulties taking part in mealtimes, their health and nutrition is impacted.