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Our Intake Process

  1. To begin the process, you can
    • Call us at (585) 275-2986 to request the intake paperwork. We will mail the necessary forms.
    • Print the paperwork, then send us the completed forms by mail or fax.
  2. If the child is not already a patient in our system, a secretary will call the parent/caregiver once we receive the completed paperwork. We will collect the child's demographic and insurance information.
  3. We will review the intake paperwork.
  4. A member of our Intake team will call the parent/caregiver to discuss the child. We will make sure our services are appropriate and schedule an appointment. We will suggest more appropriate services if the child will be better served elsewhere.

Intake Paperwork

This paperwork helps us make accurate diagnoses and referrals. We appreciate your help in gathering all of this information before the visit.

If you need help gathering this information, consider asking your child’s service coordinator, case manager, PCP office, or teacher. If you need help with completing the paperwork, you can call (585) 275-2986 and ask to speak with our social worker.

We look forward to talking with you once your information packet has been received. Please include all telephone numbers where you can be reached during the day.


  1. Complete the following forms:

    Note: If your child has an appointment with the Pediatric Feeding Disorders Program, please complete the Feeding Forms instead of the following.
  2. Obtain a copy of the evaluation report from your child’s most recent EI, preschool, or school testing.
  3. Send the completed forms and report together to the following address:
    Intake Coordinator
    Kirch Developmental Services Center
    601 Elmwood Avenue, Box 671
    Rochester, NY 14642

    Fax: (585) 275-3366

    Sending pieces of information separately may delay the review process.
  4. Our Intake team will review your information then call you. We will either schedule an appointment or talk about other options for your child.

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 following websites explain the process for requesting an evaluation: