Our Intake Process

Children 0-5

1. To begin the process, please
   1. Call us at (585) 275-2986 to ask for our intake paperwork forms. OR
   2. Print the forms below, then mail or fax them to us.
2. We will review the paperwork when all forms are returned.

3. A member of our intake team will call the parent/caregiver to discuss the child.

4. We will make sure our services are a right fit for your child and schedule a visit. We will suggest other services if we are not the best source of care.

Children 5 and older

1. To begin the process, please call (585) 275-2986 to schedule a brief phone call with our intake team.
2. A member of our intake team will call at the scheduled time to discuss the child. We will see if our services may be a good fit, or if the child will be better served elsewhere.

3. If our services may be a good fit for your child, we will send you intake paperwork to complete and return. We will also need school testing sent to us. If we are not the best source of care, we will suggest other resources.

4. Once we received your completed intake forms, we will review the paperwork.

5. A member of our Intake team will call the parent/caregiver to further discuss the child and the completed paperwork.

6. We will make sure our services are a right fit for your child and schedule an appointment. We will suggest other services if we are not the best source of care for the child.

Intake Paperwork & Instructions

If you need help gathering this information, please ask your child’s service coordinator, case manager, PCP office, or teacher.

If you need help filing out the paperwork, please call (585) 275-2986 and ask to speak with our social worker.

Note: If your child has an appointment with the Pediatric Feeding Disorders Program, please complete the Feeding Forms instead of the following.

1. Please complete the following forms:

• Parent Questionnaire for New Patients (Spanish Version)
  A parent or legal guardian should fill this out to the best of their ability. If completed by someone other than a parent, please include papers of legal guardianship.
• Pre-school/Early Intervention Questionnaire or Educational Questionnaire - School Age 
  This form should be filled out by a teacher, special educator, or early intervention service provider (SLP, OT, PT) to the best of their ability.
• Uniform Referral Form
  This is intended for your child’s pediatrician. If another physician is referring your child, they can complete the form.

2. Get a copy of the evaluation report from your child’s most recent EI or preschool testing.
3. Fax all the forms together to (585) 742-4217 or mail to:
   Intake Coordinator
   Developmental and Behavioral Pediatrics
   601 Elmwood Avenue, Box 278877
   Rochester, NY 14642

Returning Patients Intake Paperwork

1. Please complete the following forms:

• Parent Update for Returning Patients

Evaluation Report for School-Based Services

Children with developmental concerns should have an evaluation for school-based services. We do not typically schedule children without this information.

The websites below explain the process for requesting an evaluation:

• www.health.ny.gov/publications/0532.pdf
• NYSED a Parent's Guide to Special Education