Little boy drinking from a cup
  1. Select a form below;
  2. Print and complete the form;
  3. Return the completed form in one of the following ways:

    • In-person during your next appointment
    • By FAX: 410-578-2654
    • Mail it to the following address:

    Mt. Washington Pediatric Hospital

    Attn: Feeding Day Program
    1708 West Rogers Avenue
    Baltimore, Maryland 21209

Please Select a Form:

  1. New Patient Information Form (PDF)
  2. Food Intake Record (PDF)
    If your child has an appointment in our feeding clinic or has an appointment for a follow-up in the feeding day treatment program, you will be asked to document his/her intake for 3 days. This information will help our dietitian determine your child's nutritional needs.
  3. Feeding Day Treatment Program Family Questionnaire (PDF)
    If your child is admitted to our feeding day treatment program, we will ask you to complete this questionnaire ahead of time. This information will help our feeding team understand all of the issues involved in your child's care, including any equipment needs or any special preparations that we may need to make. We ask that you fill out this questionnaire before your child's first day and either mail it to the address shown above or fax it to 410-578-5322.
  4. Parent Satisfaction Questionnaire (PDF)
    If your child has completed the feeding day treatment program, please provide us with feedback by completing this satisfaction questionnaire. Please note that this questionnaire will be kept confidential. Your feedback will help us improve our program.

Outpatient appointments and program referrals can be made by calling 410-367-2222.