Intake Form

Wee Potty Client Intake Form

* Indicates required field

Your first and last name *

Address *

City, province *

Phone number *

Email address *

Which service are you interested in: *

In-home Consultation Phone Consultation Unsure

Child's name *

Child's age *

Years, months

Have you previously tried to potty train this child? *

If yes, please specify which methods you used and what the challenges were.

Do you have other children? *

Yes No

If yes, please specify age(s) *

For previous children, what was your experience with potty training? *

What are your concerns and/or fears with the potty learning process? *

What is your child's typical diet like? *

Does your child have any food allergies or sensitivities? (If yes, please specify) *

Does your child have constipation? *

Never Sometimes Frequently I don't know

What type of diaper has your child been wearing? *

Disposable Cloth Disposable and Cloth None - Underwear/ Training Pants

Where does your child typically spend his or her day? *

Daycare/ Preschool At home with parent or other caregiver Other (please specify)

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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