GIE Weaning Program Form

Thank you for trusting Growing Independent Eaters to work with your family on your weaning journey! We consider it such an honor and pleasure. Before we move forward to the Weaning Program, please fill out the form below with as much detail as you can, and feel free to contact us with any questions at info@gieaters.com.

Upon receipt of this form, your team will begin crafting your weaning plan, which will be sent to you 5-7 business days after your meeting with the Mental Health Social Worker.

Date

YYYY

Parent/Guardian's Name

First Name

Last Name

Email Address

Child's Name

First Name

Last Name

Child's Date of Birth

YYYY

Child's current age

What is your child's current weight? This should be within the last 7 days as this will be used as the pre-wean weight

What is your child's current length/height? This should be within the last 7 days as this will be used to calculate pre-wean body composition.

Date these measurements were taken

YYYY

How long has your child been receiving tube feeds?

What type of tube does your child currently have?

Please indicate if your child’s level of dependence on tube feeds is exclusive (e.g., tube feeding regimen is designed to meet all of your child’s nutritional needs) or partial (e.g., tube feeds are designed to supplement oral diet)

What is your child's current feeding schedule? How much does your child currently take in, of what, and when?

What foods does your child currently accept?

What drinks does your child currently accept?

What has been the best cup or bottle out of all you've tried?

What is your child's current sleeping schedule?

What are other important family routines?

Does anyone else provide consistent care? Who and how often?