Kindering is an Early Support Center

We help children from birth to age 3 who have developmental delays. We offer services in communication, motor and play skills, social skills, and self-help skills.

The information we gather at intake is kept confidential and is just for our purposes here at Kindering to let the evaluation team know a little more about your child when he/she comes in for the evaluation.

When we receive your completed online intake one of our team will be in touch to schedule your child in to an evaluation time. Please do not come to Kindering for an evaluation without an appointment.

If you are a pediatrician/agency/organization referring a kid and family to our program, please fill out our Referral Form instead.

Child's Information
Child's Name*
First Last
Gender*
Child's Birth Date*
MM slash DD slash YYYY
Child's age in months*
Please select the child's age in months above to view the appropriate set of questions for your child according to their age.
If your child is older than 36 months (3 years or older) please use our KidsClinic referral form.
How would you describe your child’s ethnicity or race?*
Please specify Other:
Child's Primary Address*
Street Address Address Line 2 City State ZIP Code
County*
- King
- Snohomish
Your address is within our service area
Your address may not be within our service area. To find out the service provider in your area, call 1-800-322-2588 OR use our King County Early Intervention Provider Services Map at http://www5.kingcounty.gov/eiproviders/ . If Kindering serves your address, please continue filling out the form.

Our Service Areas

98012 and 98021: Home addresses within the Northshore or Edmonds School Districts.

98027: Home addresses north of May Valley RD.

98033: Home addresses in Bellevue.

98034 and 98036: Home addresses East of I-5.

98037: Home addresses East of I-5 and in the Edmonds School District.

98052: Home addresses north of NE 124th.

98053: Home addresses in the Lake Washington School District.

98058: Home addresses north of SE 128th or NE 4th.

98072, 98077 and 98296: Home addresses in the Northshore or Lake Washington School Districts.

98087: Home addresses East of I-5 and in the Northshore School District

Find Your School District
Your address is not within our service area. To find out the service provider in your area, call 1-800-322-2588 OR use our King County Early Intervention Provider Services Map at http://www5.kingcounty.gov/eiproviders/ .
Demographic Information
These questions help us to ensure that we are serving families from all sectors of our community and also help us to obtain funding. Answering these questions is optional.
Have you or your child experienced homelessness in the last three years? (If you do not own/rent your own home, please select yes on the options below if in the past three years you or your child have lived: In a motel; In a shelter; Moving from place to place/couch surfing; In someone else’s house or apartment with another family; In a residence with inadequate facilities (no water, heat, electricity, etc.); In a car, In a park, In a campsite, or In a similar location; In transitional housing.)
- Yes
- No
What type of housing are you currently in?*
- Transitional Housing
- Permanent Housing
Are either of your child’s parents a U.S. veteran?
- Yes
- No
What is the primary language spoken in your home?
Enter Primary Language Spoken*
How would you characterize your family's annual income?
Can you share your family income and size? This information helps with our fundraising efforts and we will never share your personal information. We ask your family size to learn how many people depend on your income. Your family includes you and your partner, as well as any child or relative who depends on you for more than half their support (even if they don’t live with you).
Family Size*
If your family size is more than 6, please specify number below.*
Please enter a number less than or equal to 20.
Primary Contact's Information
Primary Contact's Name*
First Last
Date of Birth:*
MM slash DD slash YYYY
Primary Contact relation to child*
Specify Other:*
Marital Status*
- Single, never married
- Married or Domestic Partnership
- Widowed
- Divorced
- Separated
Are you the legal guardian?*
- Yes
- No
Primary Contact's Email
Primary Phone Number*
Other Phone Number (Home, Cell)
Work Phone Number
Family/Home
If you listed yourself as the Primary Contact, please do not list yourself again.
List other family members below.
Name
First Last
BirthDate
MM slash DD slash YYYY
Relation
Specify Other:*
Name
First Last
BirthDate
MM slash DD slash YYYY
Relation
Specify Other:*
Name
First Last
BirthDate
MM slash DD slash YYYY
Relation
Specify Other:*
Name
First Last
BirthDate
MM slash DD slash YYYY
Relation
Specify Other:*
Please list additional names, birthdates, and relationships to child for all people living in your home.
Primary concern:*
Your child’s pediatrician is Dr.*
First Last
Pediatrician's Phone Number*
Referral Source*
Specify Other:*
Development and health history
List any medical diagnoses your child has:
Has your child had any previous developmental or medical testing?
- Yes
- No
Where?
Upload tests
Accepted file types: pdf, doc, docx, xls, xlsx, Max. file size: 800 MB.
Are there any medical specialists following your child?
- Yes
- No
Please list providers and hospital/clinic*
Has your child received any therapy services before?
- Yes
- No
Where?*
Have you or your pediatrician observed any characteristics of autism or ASD?
- Yes
- No
Are there any vision concerns?*
- Yes
- No
Please Describe:*
Are there any hearing concerns?*
- Yes
- No
Please Describe:*
Birth history
At how many weeks gestation was your child born? (Full term = 40 weeks)*
Please enter a number less than or equal to 45.
Did the child spend any time in the NICU?
- Yes
- No
How long?
What hospital or location was your child born at?*
Hospital/Location's City, State, or Country*
Were there any complications during pregnancy or delivery?
- Yes
- No
Please describe complication(s)*
What was your child’s birth weight?*
Does your child have any allergies?
- Yes
- No
List allergies:*
Is your child taking any medications?
- Yes
- No
List medication(s):*
Has your child had any ongoing ear infections or very high fevers?
- Yes
- No
Natural Environment
Where does your child typically spend the day?*
- Home
- Daycare
If at daycare, please list the name and address. How many hours each day/week?*
Cognitive/Social

Cognitive development refers to problem solving, play and learning skills.

Social development refers to the ability to manage feelings, express emotions, and develop relationships with other people.
Please describe any concerns with your child’s problem solving, playing, learning skills, managing of feelings, expressing emotions, developing relationships with other people or any other social behavior.*
Describe your concerns with your child’s social development.*
Does your child: (Check all that apply)*
- Enjoys physical contact, cuddles
- Makes eye contact
- Let's you know when in distress-cries?
- Soothed when picked up
- Responds to sounds and/or voice
- None of the above
Does your child:(Check all that apply)*
- Searches with eyes for sounds
- Inspects own hands
- Searches eyes and mouth when you talk to him
- Begins to play with rattle
- Responds with smile when approached by parents
- Draws attention to self when in distress
- None of the above
Does your child:(Check all that apply)*
- Smiles when smiled at
- Communicates hunger, discomfort through crying or facial expressions
- Quiets down when picked up
- Anticipates being picked up
- None of the above
Does your child:(Check all that apply)*
- Opens mouth for spoon
- Tracks objects horizontally and vertically
- Explores with hands
- Laughs and squeals when happy
- Knows familiar faces
- None of the above
Does your child:(Check all that apply)*
- Opens mouth for spoon
- Tracks objects horizontally and vertically
- Explores with hands
- Laughs and squeals when happy
- Knows familiar faces
- Shakes, bangs, throws and drops objects/toys
- Bangs toys together and/or against a table
- Turns to loud noises
- Plays peek-a-boo and/or pat-a-cake
- Has some anxiety around strangers
- None of the above
What kind of toys does your child like to play with right now?*
Describe her/his play:*
Does your child:(Check all that apply)*
- Likes to play interactive games such as peek-a-boo, chase or tickle
- Copies sounds
- Crawls to a toy when she/he wants it
- Understands simple commands, such as “No” or “Up?”
- Interacts with other children
- Interacts with other adults
- None of the above
Does your child:(Check all that apply)*
- Likes to play interactive games such as peek-a-boo, chase or tickle
- Copies sounds
- Crawls to a toy when she/he wants it
- Understands simple commands, such as “No” or “Up?”
- Interacts with other children
- Interacts with other adults
- Figures out creative ways to get the things he/she cannot reach—such as using a spoon or a stick
- Listens to stories
- Recognizes self in the mirror
- Hugs dolls or stuffed animals
- None of the above
Does your child becomes anxious when separated from Mom and/or Dad?*
- Yes
- No
What does that look like*
Do you see your child engaging in pretend play?*
- Yes
- No
Does your child like to play interactive games such as peek-a-boo, tickle or hide and seek?*
- Yes
- No
Describe how your child responds/interacts with other children?*
Describe how your child responds/interacts with other adults?*
Does your child trade toys with another child?*
- Yes
- No
Is he/she able to wait for his/her turn with a desired toy?*
- Yes
- No
Does your child follow single step directions? Ex: “Pick up the ball.”*
- Yes
- No
Does your child follow multiple step directions? Ex: “Pick up the ball and put it on the table.”*
- Yes
- No
Does your child become anxious when separated from Mom and/or Dad?*
- Yes
- No
Does your child become anxious when separated from Mom and/or Dad?*
- Yes
- No
What does that look like?*
Communication

Communication includes both expressive and receptive language.

Expressive language refers to one’s use of words and gestures to communicate their wants and needs.

Receptive language refers to one’s understanding of words, pictures, and gestures.
Please describe any concerns with your child’s language development.*
Does your child:(Check all that apply)*
- Cries when hungry or uncomfortable
- Makes comfort sounds – cooing
- Cry is monotonous/repetitive, nasal, one long breath
- None of the above
Does your child:(Check all that apply)*
- Laughs
- Coos (aah, ee, oy)
- Squeals
- Cry varies to indicate needs (e.g. hunger, pain)
- None of the above
Does your child make cooing, gurgling sounds*
- Yes
- No
Does your child:(Check all that apply)*
- Babbles (e.g. “bababa,” “dadada,” “gagaga”)
- Responds to his/her name
- Understands a few words
- None of the above
Does your child:(Check all that apply)*
- Uses about 5 words regularly
- Understands simple commands (e.g. “no,” “up”)
- Imitates two word sentences such as “Mommy eat.”
- Tells what she/he wants by pointing, grunting or pulling parent
- Requests help
- None of the above
Does your child:(Check all that apply)*
- Says hi, bye, mama, dada
- Imitates sounds, words, and/or gestures
- Points
- Makes eye contact
- I understand what my child is saying to me
- People outside the family understand my child
- None of the above
Can your child:(Check all that apply)*
- Find pictures in a book or familiar objects in the room if you ask?
- Show you some body parts?
- None of the above
Can your child find familiar toys in the room or find pictures in a book when you ask?*
- Yes
- No
Please describe how your child communicates with you:*
Does your child babble and make sounds?*
- No
- Yes
Does your child babble, make sounds, imitate sounds?*
- Yes
- No
Does your child respond to music with motion?*
- Yes
- No
Does your child respond to her/his own name?*
- Yes
- No
Is your child using words?*
- Yes
- No
If so, approximately how many words does your child use?*
How does your child tell you when she/he wants something?*
What happens when your child is not understood?*
Motor

Motor includes both fine motor and gross motor.

Fine motor coordination skills refer to the area of development which includes reaching, grasping, and manipulating objects.

Gross motor skills refer to the area of development that involves large muscle movements to complete tasks such as sitting, crawling, walking, and jumping.
Please describe any concerns with how your child is reaching, grasping, manipulating objects, sitting, crawling, or other types of movement.*
Does your child:(Check all that apply)*
- Turns head to both sides while lying on his/her back
- Lifts head when lying face down
- Holds head to one side when lying face down
- Lifts head when held at shoulder
- Moves are symmetrical
- None of the above
Does your child:(Check all that apply)*
- Lifts head and chest when on stomach
- Rotates and extends head, follows your movements by turning head side to side
- Rolls from front to back
- Keeps hands open 50% of time
- Reached toward toy without grasping
- Grasps toy actively
- Look from one object to another
- Follows with eyes
- None of the above
Does your child:(Check all that apply)*
- Points with his/her fingers
- Picks up small toys with one hand
- Tries to pick up small bits of food by using a raking motion or using fingertips
- Crawls, creeps or scoots
- Sits up, sometimes by leaning on his/her hands
- Stands next to furniture by leaning for support
- Picks up a toy and puts it in mouth
- Passes toys easily from one hand to the other
- Picks up a toy in each hand and hold for about 1 minute
- None of the above
Does your child:(Check all that apply)*
- Stacks three blocks
- Walks
- Climbs on most everything
- Stoops to pick up a toy
- Climbs on furniture to get what she/he wants
- Points to pictures in a book
- None of the above
Does your child:(Check all that apply)*
- Walk
- Run
- Jump
- Climb
- Go up and/or down the stairs
- Stack blocks
- Scribble with a marker/crayon
- Pull off socks or a hat
- Turn pages in a book
- Hold onto a spoon or fork
- None of the above
Does your child:(Check all that apply)*
- Walk
- Run
- Jump with 2 feet
- Climb
- Walk up and/or down stairs on her/his own
- Walk up and/or down stairs with help
- Stack blocks
- Scribble with a marker or crayon
- Pull off socks or a hat
- Turn pages in a book
- Hold onto spoon or fork
- None of the above
If your child can go up and/or down the stairs, what does that look like?*
Does your child:(Check all that apply)*
- Lifts head when held at your shoulder
- Lifts head and chest when lying on his/her stomach
- Follows a moving object or person with his/her eyes
- Grasps a rattle when given to him
- Wiggles and kicks with arms and legs
- None of the above
Does your child:(Check all that apply)*
- Pulls up to a sitting position when your holding their hands
- Sits with only a little support
- Rolls over
- Pushes up on extended arms while on tummy
- Bounces when held in a standing position
- Reaches for and grasps objects
- Shakes a rattle
- Moves toys from one hand to another
- Explores by mouthing objects
- None of the above
Does your child move around?*
- Yes
- No
Is she/he (Check all that apply)*
- Walking
- Crawling
- Scooting
- None of the above
Does your child stand alone momentarily?*
- Yes
- No
Does she/he walk with one hand held?*
- Yes
- No
Does your child walk without help?*
- Yes
- No
Does your child feed her/himself finger food such as raisins or cheerios?*
- Yes
- No
Can your child show you some body parts?*
- Yes
- No
Adaptive

Adaptive living skills refer to the area of development which includes self-help skills such as feeding and dressing, and also calming and coping.
Please describe any feeding or sleeping concerns.*
Regulatory/adaptive:(Check all that apply)*
- Opens and closes mouth in response to food stimulus
- Coordinates sucking, swallowing and breathing
- None of the above
Regulatory/adaptive:(Check all that apply)*
- Easily take bottle or breast and suck well
- Brings hand to mouth
- Naps frequently
- Stays awake for longer periods without crying – usually in evening
- None of the above
Sleeps through the night?*
- Yes
- No
How many naps in a day?*
Has/Does your child:(Check all that apply)*
- Started on solid foods
- Sleeps through the night
- None of the above
Has/Does your child:(Check all that apply)*
- Started on solid foods
- Sleeps through the night
- Drinks juice or water from a cup when parent holds it for her/him
- Feeds self a cracker
- Helps with dressing by pushing arms through the sleeves
- None of the above
Has/Does your child:(Check all that apply)*
- Drinks from a cup
- Feeds self with fingers
- Helps to undress her/himself
- None of the above
Does your child:(Check all that apply)*
- Eat crunchy foods (Ex: crackers or chips)
- Eat soft foods (Ex: applesauce or yogurt)
- None of the above
Does your child:(Check all that apply)*
- Eat crunchy foods (Ex: crackers or chips)
- Eat soft foods (Ex: applesauce or yogurt)
- Eat texture foods (Ex: rice or oatmeal)
- None of the above
Is your child a picky eater?*
- Yes
- No
Does your child eat a variety of foods?*
- Yes
- No
Describe your child’s eating habits:*
What are your child’s favorite foods?*
Does your child sleep through the night?*
- Yes
- No
Can your child fall asleep by her/himself, or does your child need someone else there?*
- By self
- Needs someone
Does your child nap during the day?*
- Yes
- No
How many naps in a day?*
What is your child’s sleep schedule like?*
Does your child help with dressing?*
- Yes
- No
If so, please describe how.*
Your child prefers to play:(Check all that apply)*
- Alone
- With others
- Combination of the two
In general, do you feel that your child plays safely?*
- Yes
- No
Does she/he seem overly sensitive to smells, textures or sounds?*
- Yes
- No
How would you describe your child’s personality:*
Insurance Information
Insurance Company:*
Group Number:*

Insurance group number
ID/Member Number:*

Insurance ID or Member Number
Who is the primary holder of your health insurance?*
First Last
What is the primary holder’s date of birth?*
MM slash DD slash YYYY
If the insurance is through an employer, what is that employer’s name?
Secondary insurance company:
Secondary Insurance Group Number:

Insurance group number
Secondary Insurance ID/Member Number:

Secondary Insurance ID or Member Number
Who is the primary holder of your Secondary health insurance?
First Last
What is the primary holder’s date of birth?
MM slash DD slash YYYY
If the Secondary insurance is through an employer, what is that employer’s name?
Would you like a medical interpreter?
- Yes
- No
The way families get started at Kindering is through a full developmental evaluation.

Our full developmental evaluation happens at our Kindering office and takes about 2 hours. The evaluation team is made up of 2-3 specialists in the areas of speech, education and physical or occupational therapy. During the first part of the appointment, the team looks at your child’s development in all the different areas of development. They will also interview you and get information on routines and how things go at home They’re doing standardized testing, but it looks like play. You will remain with your child for the entire process. When they’ve gathered all the information they need, the team will step out of the room to score the tests, and you’ll get a break. When they return, they’ll give you verbal and written feedback regarding your child’s performance, as well as information on eligibility and their recommendations. In order to qualify for services at Kindering, a child needs to show a 25% delay in one or more areas on the standardized testing or have a qualifying diagnosis. If you child qualifies for services at Kindering, we will provide those services for them within 45 days of the initial referral date. You have the right at any time to accept or decline Kindering’s services—there is no obligation to have the evaluation or to go ahead with services after the evaluation.

We will bill your insurance for the initial evaluation, and it is at no cost to you. If there are any co-pays or co-insurance, you will not be responsible for that cost. If your child qualifies for on-gong services, there are two options for payment; you can choose to pay a monthly fee based on income and family size, or use your insurance, and you will be responsible for any deductibles or copays.
Terms of Use
I have read and agree with the terms of use.*
- Yes
Date*
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

Save and Continue Later

Kindering is an Early Support Center

If you are a pediatrician/agency/organization referring a kid and family to our program, please fill out our Referral Form instead.

Child's Information

Please select the child's age in months above to view the appropriate set of questions for your child according to their age.

Our Service Areas

Demographic Information

Primary Contact's Information

Family/Home

If you listed yourself as the Primary Contact, please do not list yourself again.
List other family members below.

Development and health history

Birth history

Natural Environment

Cognitive/Social

Communication

Motor

Adaptive

Insurance Information

Title

Contact Us

Connect With Us

Our Mission

Kindering is an Early Support Center

If you are a pediatrician/agency/organization referring a kid and family to our program, please fill out our Referral Form instead.

Child's Information

Please select the child's age in months above to view the appropriate set of questions for your child according to their age.

Our Service Areas

Demographic Information

Primary Contact's Information

Family/Home

If you listed yourself as the Primary Contact, please do not list yourself again.List other family members below.

Development and health history

Birth history

Natural Environment

Cognitive/Social

Communication

Motor

Adaptive

Insurance Information

Title

Contact Us

Connect With Us

Our Mission

If you listed yourself as the Primary Contact, please do not list yourself again.
List other family members below.