Potty Over Here
Potty Training Questionnaire
Parent Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Child Name
First Name
Last Name
Child's Birthday
*
-
Month
-
Day
Year
Date
Emergency Contact
*
First Name
Last Name
Emergency Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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What is the child’s general personality?
Does your child demonstrate awareness of bodily functions related to elimination? (i.e. find an isolated spot or get into a specific position to eliminate, verbally indicate, etc.)
YES
NO
Birth order?
OLDEST
MIDDLE
YOUNGEST
ONLY
TWIN
TRIPLET
SOON-T0-BE OLDER BROTHER/SISTER
Does your child have any developmental delays?
*
For how long does your child typically remain dry (wearing a diaper)?
LESS THAN 30 MINUTES
ABOUT 1 HOUR
UP TO 2 HOURS
MORE THAN 2 HOURS
MORE THAN 5 HOURS
ONLY NEED BOWEL TRAINING
Does your child have regular bowel movements? How often and what time of day?
What does your child wear?
DIAPERS
PULL-UPS
UNDERWEAR
TRAINING PANTS UNDERWEAR
Is the child in a daycare or other caregiver’s care at any point during the week?
Are there any time constraints on when child needs to be potty trained? (ie; entering preschool, where they MUST be trained?
Have you tried potty training your child before contacting POH? If so, please describe the experience(s):
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At what time does your child typically wake up in the morning?
Hour Minutes
AM
PM
AM/PM Option
Does your child nap? If yes, around what time and for how long?
At what time does your child typically eat dinner?
Hour Minutes
AM
PM
AM/PM Option
What is your child's favorite:1) snack item 2) character/show 3) toy/game
What does your child use for drinking?
SIPPY CUP-SPOUTt
SIPPY CUP-STRAW
OPEN CUP
BOTTLE
Other
How would you describe your child's diet?
*
Does your child drink milk before bed?
YES
NO
Does your Child have any allergies? If so, please list:
*
At what time does your child go to sleep at night?
Hour Minutes
AM
PM
AM/PM Option
Where does your child sleep?
CRIB
CONVERTED CRIB
BED
IN THE BED WITH PARENT(S)
Other
Any history of constipation?
*
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Do you beleive a Reset in order?
What do you think in your heart is the problem?
*
What dates are you avaliable to begin potty training?
-
Month
-
Day
Year
Date
How did you hear about us?
I understand my next step is to fill out out the service agreement and submit payment via Venmo to Potty Over Here.
I agree
Which Service are you interested in?
Phone Consult
Potty Coach on Demand
1 Day Potty Support
3 Day Potty Experience
Submit
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