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Wee Potty Client Intake Form
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Indicates required field
Your first and last name
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Address
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City, province
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Phone number
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Email address
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Which service are you interested in:
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In-home Consultation
Phone Consultation
Poop Consultation
Unsure
Child's name
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Child's age
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Years, months
Have you previously tried to potty train this child?
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If yes, please specify which methods you used and what the challenges were.
Do you have other children?
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Yes
No
If yes, please specify age(s)
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For previous children, what was your experience with potty training?
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What are your concerns and/or fears with the potty learning process?
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What is your child's typical diet like?
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Does your child have any food allergies or sensitivities? (If yes, please specify)
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Does your child have constipation?
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Never
Sometimes
Frequently
I don't know
What type of diaper has your child been wearing?
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Disposable
Cloth
Disposable and Cloth
None - Underwear/ Training Pants
Where does your child typically spend his or her day?
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Daycare/ Preschool
At home with parent or other caregiver
Other
That’s it! Thank you for completing the questionnaire. Please submit using the button below and I will be in touch soon!
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