KidsClinic Waitlist/Referral (pediatric therapy)

Thank you for taking the time to fill out the following questions.

On Submission you will be added to the KidsClinic waitlist (currently ~ 7 months for all services and initial evaluations)

Child's First Name(Required)

Child's Last Name(Required)

Child's DOB(Required)

Our clinic serves children up to age 11. If your child is already 10, please be aware that due to current wait times, we may not be able to schedule services before they age out of our care. We’re happy to provide a referral list for clinics that support children over age 10, and we’re here to help guide you through that process.

Child's gender(Required)

Has your child received services at Kindering before?(Required)

Yes

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you have a different mailing address?

Yes

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

County of Residence

King

Snohomish

Other

Please write in other county

Family Main Contact's First Name(Required)

Family Main Contact's Last Name(Required)

Family Main Contact email address(Required)

Best daytime phone number(Required)

Relationship to child(Required)

Name of person completing form

Same as above

Name

Relationship to Child

Referrer's preferred contact information (email or phone)

What is the primary language spoken in your home?(Required)

Would you or this child benefit from an interpreter?(Required)

Yes

Does your child have any diagnoses?(Required)

Yes

If yes, for what, where from, and when?

Please share the current list of all providers and services (therapy, medical, etc.) for your child.

Has your child had any formal developmental evaluations completed in the past year?(Required)

Yes

If yes: When and where was this completed? What areas of development were evaluated (speech, motor, etc.)? Was it for your child's transition to the school district?

Does your child have an IEP (Individualized Education Plan)?(Required)

Yes

Which services are you completing this intake for? (See description below)(Required)

Speech Therapy

AAC (Augmentative Alternative Communication) Evaluation and/or Support

Occupational Therapy

Physical Therapy

Feeding Therapy

Feeding Groups

Social Groups

Speech Therapy: Addresses speech sound development, language skills, and/or social/play skills.

Alternative/Augmentative Communication (AAC) Clinic (Evaluation/Support): AAC refers to forms of communication that supplement or produce speech when a person is not able to speak for themselves, using items like picture boards, iPads, etc. Candidates for AAC may have a severe speech impediment or are not yet speaking.

Occupational Therapy: Addresses using your child’s interests to support their participation in the activities they want to and need to do. E.g., Play skills, executive functioning, sleep, sensory regulation, and emotional regulation, etc.

Physical Therapy: Addresses development of gross motor skills necessary for exploring their natural environment with improved independence and confidence. This includes management of complex conditions, strengthening, balance strategies, equipment management (ex. braces and wheelchairs), coordination, motor planning. Physical therapy also supports social emotional learning around exertion, participation with friends, exploration of internal motivation for movement, and persistence through challenging activity.

Feeding Therapy: Addresses oral motor skills, swallow safety, increasing food repertoires, sensory aversions.

Feeding Groups: Addresses feeding goals in a small group setting to learn from peers.

Social Groups: Addresses OT, PT, speech therapy goals in a small group setting to learn from peers.

Does your child already have an AAC device?(Required)

Yes

Preferred Kindering Location to Receive Services

Bellevue

Bothell

Redmond

Bellevue or Bothell

Bellevue or Redmond

Bothell or Redmond

Any

Preferred Appointment Time (select all that apply)

Please note that our availability on Friday is limited, which may result in longer wait times for appointments. Currently, we have only one provider available on Friday afternoons. If you’re hoping to be seen sooner, we recommend exploring other clinics in the area that may offer earlier availability. We’re happy to share a referral list with you to support your search.

Please describe in detail your current concerns and challenges. Why are you seeking services from our clinic? At what age did you start to have those concerns for your child?(Required)

How are your concerns affecting your child's ability to engage with family members? How about in the classroom? How about during activities?(Required)

Have there been any significant life events that may or may not be contributing to your concerns? (PTSD, abuse, trauma, anxiety, foster care)

Yes

If yes, what are those life events?

Have you explored your concerns with any other professionals in the past?

Yes

If yes, what other professionals?

If no, why not?

Once submitted, you will receive a confirmation email from one of our intake coordinators. Please check your spam or junk folder if it does not arrive in your inbox.

KidsClinic Waitlist/Referral (pediatric therapy)

On Submission you will be added to the KidsClinic waitlist (currently ~ 7 months for all services and initial evaluations)

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