Your Name *

First Name

Last Name

Your Child's Name *

First Name

Last Name

Your Child's Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Which of the following apply to your child? *

Please select all that apply.

My child is a picky eater.

My child has been diagnosed with ARFID.

My child has an eating disorder other than ARFID.

My child has sensory processing disorder.

My child eats less than 10 foods.

My child has BCBS NC or NC State Health Insurance.

My child lives in North Carolina.

Which class time do you prefer? *

7-7:30pm

8-8:30pm

Either works for me!