FOR PROFESSIONALS

REFERRAL FORM
  • Close-up of a yawning newborn baby wrapped in a white blanket with a striped blue, pink, and white background.

    Identify Feeding or Oral-Function Concerns

    Look for common signs such as poor latch, long or inefficient feeds, maternal nipple pain, clicking or air intake, reflux-like symptoms, poor weight gain, feeding fatigue, difficulty moving to solids, speech/oral-motor concerns in toddlers, or mouth breathing/sleep-disordered patterns.

  • A young child with a towel over their head, lying on their stomach on a bed or soft surface, looking directly at the camera with a slightly puckered expression.

    Refer to a Feeding Specialist First

    Before considering frenectomy, infants and toddlers should receive a functional feeding evaluation from an IBCLC, pediatric SLP, or OT trained in oral-motor development. This step confirms the source of the problem, distinguishes structural from functional issues, ensures proper pre-release preparation, and helps avoid unnecessary procedures.

  • A baby with light skin, blue eyes, and brown hair sitting on a fluffy white rug indoors, smiling and looking at the camera, wearing a gray long-sleeve onesie with dark buttons.

    Send Our Referral Form With Clinical Notes

    After a feeding specialist has evaluated the child, please send the WV TOT Referral Form, feeding assessment findings, recent growth/weight details, and any relevant chart notes. This allows our team to understand your concerns and coordinate care efficiently. Forms may be sent via secure email or fax.

  • A young child with light skin and short hair lying on a beige pillow, drinking milk from a bottle held by an adult with painted dark nails.

    We Coordinate Care & Provide Follow-Up

    After receiving your referral, we contact the family to schedule an oral-function exam, review all notes, and collaborate with their feeding specialist. If a release is indicated, we provide gentle CO₂ laser treatment, simple aftercare, coordinated post-release therapy, and follow-up updates to you. Our shared goal is improved feeding, comfort, and long-term functional success.