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OUR SERVICES
KINDERING FAMILIES
GET INVOLVED
ABOUT US
CONTACT US
- MAKE A REFERRAL
DONATE
Search for:

Search for:

KidsClinic ReferralHo-Duong Nguyen2024-03-28T12:06:04-07:00

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)

MM slash DD slash YYYY

Child's gender(Required)

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

Yes

No

Home Address(Required)

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

Do you have a different mailing address?

Yes

No

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)

Mother

Father

Foster Mother

Foster Father

Stepmother

Stepfather

Grandmother

Grandfather

Aunt

Uncle

Sister

Brother

Guardian

Other

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)

English

Amharic

Arabic

Armenian

Azerbaijani

Bengali

Bulgarian

Burushaskhi

Cambodian

Cantonese

Chinese

Cushite

Danish

Dari

Dutch

Farsi

French

German

Gujarati

Hebrew

Hindi

Hmong

Hungarian

Icelandic

Italian

Japanese

Kannada

Korean

Kutchhi

Laotian

Lingala

Lithuanian

Macedonian

Malay

Malayalam

Mandarin

Marathi

Marshallese

Mixteco

Mongolian

Nepali

Odia

Odiya

Oromo

Pashto

Persian

Pohnpeian

Polish

Portuguese

Punjabi

Romanian

Russian

Samoan

Serbian

Sign

Somali

Spanish

Swahili

Tagalog

Taiwanese

Tamil

Telugu

Thai

Tigrinya

Turkish

Ukrainian

Urdu

Vietnamese

Wollof

Yiddish

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

Yes

No

Does your child have any diagnoses?(Required)

Yes

No

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

No

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

No

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

Speech Therapy

AAC (Augmentative Alternative Communication) Evaluation and/or Support

Occupational Therapy

Physical Therapy

Feeding Therapy

Social Groups

All

Select all that apply

Preferred Kindering Location to Receive Services

Bellevue

Bothell

Either

Preferred Appointment Time (select all that apply)

Monday Morning

Monday Afternoon

Tuesday Morning

Tuesday Afternoon

Wednesday Morning

Wednesday Afternoon

Thursday Morning

Thursday Afternoon

Friday Morning

Friday Afternoon

Any/All

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

No

If yes, what are those life events?

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

Yes

No

If yes, what other professionals?

If no, why not?

Δ

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.

Title

Main: (425) 747-4004 | Fax: (425) 747-1069; (425) 984-2699

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Kindering Bellevue: 16120 NE 8th St, Bellevue, 98008
Kindering Bothell: 19801 North Creek Pkwy, Bothell, 98011
Kindering Redmond: 16255 NE 87th St. Suite 180, Redmond, WA 98052
Kindering Renton: 1700 Edmonds Ave NE Suite B, Renton, WA 98056

Phone: (425) 747-4004

Fax: (425) 747-1069 ; (425) 984-2699

Email: info@kindering.org

Web: www.kindering.org

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Our Mission

Kindering embraces children of diverse abilities and their families by providing the finest education and therapies to nurture hope, courage, and the skills to soar.

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