Kitchen Connoisseurs Registration

Name of Student ___________________________ DOB______________________________

Parents Name ______________________________ Parent Phone__________________________

Emergency contact __________________________ Phone_____________________________

Please describe the child's diet on a typical day:

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Food Preferences (Please place a check by all the foods the child likes:

Grains:		Vegetables:	Fruits		Milk
White Bread ___		Sweet Potatoes ___	Apple ___		Cheese ___
Wheat Bread ___		Carrots ___	Orange ___		Yogurt ___
Crackers ___		Lettuce ___	Bananas ___		Ice Cream ___
Pasta ___		Cucumbers ___	Grapes ___		Milk ___
Rice ___		Potatoes ___	Berries ___		Chocolate Milk ___
Cereal ___		Peas ___	Melons ___
Oatmeal ___		Corn ___	Applesauce ___
Popcorn___		Squash ___	Raisins ___
		Broccoli ___	Tomatoes ___
Other		Other	Other		Other
Meats, Beans, Nuts	Snacks/Other foods			FOOD ALLERGIES
Chicken ___	Cookies ___			Peanuts ___
Hotdogs ___	Chocolate ___			Peanut Butter ___
Eggs ___	Pizza ___			Shellfish ___
Hamburger ___	Chips ___			Chocolate ___
Steak ___	Candy ___			Fish ___
Fish/ Tuna ___	Tacos ___			Dairy Products ___
Shrimp ___	Popcorn___			Eggs ___
Turkey ___				Wheat ___
Ham ___				Soy ___
Nuts ___				Tree Nut (walnut, cashew, etc.) ___
Bacon ___
Other	Other			Other:

Parent Concerns:

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Kitchen Connoisseurs Objectives

This a therapeutic feeding group, designed for resistant eaters. Many times, resistant eaters are simply thought of as “very picky eaters.” This is not the case. Quite often, children are resistant eaters because of an underlying fundamental problem- usually oral-motor delay or sensory integration dysfunction- that restricts food selection. ‘Kitchen Connoisseurs’ will work with those children who suffer from a sensory integration dysfunction. Food aversions can become emotionally challenging and stressful to all involved- the child, the caretaker, and any others who join at mealtime. Furthermore, food aversions can lead to poor health. The foods many resistant eaters choose tend to be fried or sweet. With poor food choices, children will not get all the vitamins and minerals they require from their typical deficient diet.

Resistant eating has no single diagnostic test. Realizing that there is a problem must come from caretaker observation. Often times these children have associated medical diagnoses, including cerebral palsy, mental retardation, and autism, just to name a few. Medical doctors will often diagnose the main problems, but leave associated problems, including eating, to the parents or therapists. Parents, then, often have to deal with frequent tantrums associated with trying new foods.

This program has five stages to help overcome the eating hurdle: Acceptance, Touch, Smell, Taste, and Eating New Foods. It is our goal that after a child’s completion of the program, he/she will have increased the number of foods in his/her diet and also, be willing to try new food items in the future. Since many of the children will only eat items in certain food groups, proper nutrition and eating according to the food pyramid guidelines are often neglected. We hope to correct this.

Kitchen Connoisseurs will focus on its main objective of introducing new foods in five stages. Each stage of sensory development for eating has an outlined treatment plan designed to complete the goals of each stage. The complete list of activities in the treatment plan for each is too long to list here (a more thorough outline of goals and treatment plans is available upon request).

Kitchen Connoisseurs session will be held on Wednesdays from 4:00 PM to 5:00 PM. Classes will be held in the kitchen at Focus Therapy Service, Inc. Class size is limited to 7 participants. Please register early. Your child must be 5 years of age or older in order to attend.

I give permission for my child to attend the Kitchen Connoisseurs program. I am aware that there will be a small cost of $5.00 per class for each student attending, unless covered by my child’s insurance policy. Parents are encouraged to pay in monthly increments. If the student cannot attend a particular session, please notify Focus Therapy Services, Inc. 24-hours in advance. Fees are non-refundable. Donations of funding, food and food-related materials are gladly accepted.

I hereby release Focus Therapy Services, Inc. and the Kitchen Connoisseurs facilitators from any and all liability connected with my child’s participation in this therapeutic feeding program. I acknowledge that my child is participating in these activities of his/her own free will, and I assume all risk in connection thereto.

Child’s Name________________________________________

Parent’s Signature_____________________________________ Date __________________

Checks can be made payable to Focus Therapy Services, Inc., and mailed to P.O. Box 12192, New Bern, NC 28561