Intake - Kindering

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If you have a concern about your child’s development, don’t wait to contact us: evaluations are provided at no cost to your family! We offer services in communication, motor skills, social and play skills, and self-help skills. Kindering is an Early Support Center (click this link to learn more about Early Support).

The first step to get support from Kindering is to fill out the intake form below.

After you complete this form, our intake team will reach out within two business days to schedule your child for an evaluation appointment. Please wait to hear from our intake team before coming to Kindering for an evaluation. At least one legal guardian must be present at the evaluation.

If you prefer to complete this intake over the phone, or if you have questions about this form, call our intake team at (425) 984-2638.

The information you provide on this form is kept confidential and protected. Click this link to learn more about your parent rights (select your language within the website), including why we gather your information and who we share it with.

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

If you are unable to complete the form, please go to the bottom of the form and choose [Save and Continue Later]. This will provide a link to continue filling out the form at a different time. Your information is saved on our server as you enter it.

*indicates a required field

Child and Parent/Caregiver information

Child's Name*

First Last

Date of Birth*

If your child is 3 years or older, please use our KidsClinic referral form

Gender*

Early Support services are offered across the entire state, and depending on your location, you may have a variety of agencies or providers to choose from. Kindering has campuses in Bellevue, Bothell, Redmond and Renton and serve the general areas around these campuses.

Please reach out to intake (425-984-2638) if you have questions regarding your address. You can also go to Early Support for Infants and Toddlers and Developmental Bridge - King County, Washington to look up King County addresses or Snohomish County ESIT Service Area Map - Google My Maps to look up Snohomish County addresses.

Child's Primary Address*

Street Address (Include apartment or unit number if applicable) City State ZIP Code

Does your child attend childcare?

Yes
No

Childcare Information

Childcare Name Street Address City State ZIP Code

What is their typical childcare schedule?

Primary Contact's Information

Parent/Caregiver Information*

Please put the person you would like to be the point of contact.

First Last

Primary Contact relation to child*

Specify relation:*

Pronouns

Phone number*

Is this a home, cell, or work phone?

Home
Cell
Work Phone

Email for paperwork*

Is this person the child’s legal guardian?*

Yes
No

Please note that we need either one legal guardian present during the evaluation, or written consent from a legal guardian.

Additional Parent/Caregiver name (if applicable)

First Last

Additional Parent/Caregiver's Relation to child*

Specify relation:*

Pronouns

Phone number

Is this a home, cell, or work phone?

Home
Cell
Work Phone

Email

Do you want this person to be included in email communications?

Yes
No

Developmental information

Why are you seeking an evaluation? What are your, or your pediatrician’s, concerns with your child's development?

Please note, if your concern is only breastfeeding, we do not have lactation consultants on staff. However, we do have feeding therapists and can still evaluate your child.

The evaluation team will complete a full developmental evaluation, including all areas below. Do you have concerns or comments in any of these areas?

Speech and language

How your child responds when you talk to them and/or expresses themself with gestures, sounds, or words.

Yes
No

What are your concerns/comments with speech and language?

Motor

How they are moving around their environment(s), and/or how they are using their hands to play with toys.

Yes
No

What are your concerns/comments with motor skills?

Relationships and Managing Emotions

How your child engages with other people, including family and other children; how they behave when frustrated, and calm down after being upset.

Yes
No

What are your concerns/comments with relationships and managing emotions?

Cognitive

How your child plays or solves problems, or your baby’s awareness of their environment.

Yes
No

What are your concerns/comments with cognitive skills?

Feeding and other daily routines

How your child participates in sleep, eating and drinking, diaper changes, and any other daily routines.

Yes
No

What are your concerns/comments with feeding and other daily routines?

Do you have any vision or hearing concerns for your child?

Yes
No

What are your concerns/comments with vision or hearing?

At how many weeks gestation was your child born? Please write a number only (i.e. 40). (full term = 37-42 weeks)

Please enter a number less than or equal to 45.

At how many weeks and days of gestation was your child born?

What was your child’s original due date?

Did your child spend any time in the NICU?

Yes
No

What was your child’s discharge date from the NICU?

Is your child followed by any medical specialists, either in the NICU or currently?

Yes
No

Please list any medical specialists and specialty

Does your child have any medical diagnoses or allergies?

Yes
No

List any medical diagnoses or allergies.

Please upload any paperwork or documentation you have for any medical diagnoses. Screenshots are acceptable. You can also bring documentation with you to the evaluation.

Max. file size: 800 MB.

Who is your child’s pediatrician?

First Last

Pediatrician clinic name/office location?

Demographic questions

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.

How would you describe your child’s ethnicity or race?

What language(s) is your child exposed to?

Do you need an interpreter for the evaluation?

Yes
No

Interpreter language needed?

Have you or your family experienced housing instability in the past 3 years?

Yes
No

Is your family currently involved with child welfare? This includes active cases with Child Protective Services (CPS), Family Voluntary Services (FVS), Family Assessment Response (FAR), Voluntary Plan Agreement (VPA), or an open dependency court case. 

Yes
No
Unsure

Our providers specialize in supporting children by nurturing their relationships with the parents and caregivers in their lives. We recognize each person involved in child welfare can experience individual stressors. We offer caring support and guidance to families, while strengthening your child’s development.

Please put your child welfare worker’s name and contact information

This question is asking if you are a parent whose family is currently involved with child welfare; or if you are a caregiver for a child with child welfare system involvement (relative or kinship caregiver, foster parent, or a friend).

How did you hear about Kindering?

Pediatrician
Friend, self, or relative
Childcare/school
Hospital
Private therapy
Community health agency
Early Head Start
Child Welfare services
Not listed above

Specify source

Insurance Information

You may either upload photos of the front/back of your insurance cards, or fill out insurance information manually. If uploading photos, fill out Primary Holder's Name, Date of Birth, and Employer Name below.

Drop files here or

Max. file size: 800 MB.

If uploading multiple insurances, please indicate which of the uploaded files is the primary insurance.

If not listed on the card, fill in Primary holder's name, date of birth and employer name

Primary Holder's Name

Primary Holder's Date of Birth

Employer Name

If NOT uploading a photo, please select your insurance provider(s)

State insurance (Apple Health, Provider One, or Medicaid)
Private insurance (insurance from your employer, or paid marketplace insurance)
Do not have insurance

Insurance company name (i.e. Molina, United Healthcare Community Plan, Community Health Plan of Washington, Wellpoint, Coordinated Care):

Managed Care Organization (MCO) ID number

DSHS number (ends in “WA”)

Insurance company name

Insurance ID (prefix and numbers)

Group number

Who is the primary holder of your health insurance?

Date of birth of primary insurance holder

If the insurance is through an employer, what is that employer’s name?

Do you have secondary insurance you would like to use?

Yes
No

Secondary insurance provider

State insurance (Apple Health, Provider One, or Medicaid)
Private insurance (insurance from your employer, or paid marketplace insurance)

Insurance company name (i.e. Molina, United Healthcare Community Plan, Community Health Plan of Washington, Wellpoint, Coordinated Care):

Managed Care Organization (MCO) ID number

DSHS number (ends in “WA”)

Secondary insurance company name

Secondary insurance ID (prefix and numbers)

Secondary insurance group number

Who is the primary holder of your secondary health insurance?

Date of birth of secondary insurance holder

If the secondary insurance is through an employer, what is that employer’s name?

Kindering offers a developmental evaluation at one of our office locations, typically lasting about two hours.  A team of 2–3 specialists—in speech, early childhood education, physical therapy or occupational therapy—will assess your child’s development across all areas.  The evaluation involves standardized testing presented in a play-based format. The team will also interview you to better understand your family routines and any challenges at home with your child.  You will stay with your child throughout the process.

After gathering the necessary information, the team will step out briefly to score the assessments, giving you a short break. When the team returns, they will provide feedback on your child’s development, discuss eligibility for services, and offer recommendations.

To qualify for Early Support services, a child must demonstrate at least a 25% delay in one or more developmental areas, or have a qualifying diagnosis. If your child qualifies,  a Family Resources Coordinator will set up a meeting to develop a plan that addresses your priorities and concerns, and outlines the services that will take place in your home or community setting of your choice.

Participation in the evaluation is voluntary, and you have the right to accept or decline services at any time. The initial evaluation is billed to your insurance at no cost to you. If there are any co-pays or co-insurance, you will not be responsible for those costs.  For ongoing services, out-of-pocket costs may be incurred. Kindering is committed to providing services regardless of a family's ability to pay. If you have transportation or health concerns that limit your ability for an in-office evaluation, please let us know when we call you to schedule your evaluation – we are here to help.

Terms of Use

I have read and agree with the terms of use.*

Yes

Date*

Kindering welcomes families of all backgrounds! We do not not collect information related to families' immigration status.

Intake Form for Children Ages Birth to Three

The first step to get support from Kindering is to fill out the intake form below.

If you prefer to complete this intake over the phone, or if you have questions about this form, call our intake team at (425) 984-2638.

Child and Parent/Caregiver information

Primary Contact's Information

Developmental information

Demographic questions

Insurance Information

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