Aligned OT: Toileting Program
Availability for Wednesdays at 2pm (Commencing 5th August 2026)
*
Yes
Interested but not available for this time
Child's Information
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Caregiver Completing Form
*
First Name
Last Name
Relationship to Child
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the child have a diagnosis?
*
Examples: ASD, ADHD, Global Developmental Delay, Anxiety, no diagnosis
Toileting
What are your main concerns about your child's toileting?
*
Is your child currently:
*
In nappies/pull-ups full time
Using the toilet for wees
Using the toilet for poos
Toilet trained during the day
Does your child tell you when they need to use the toilet?
*
Yes
Sometimes
No
Has your child experienced constipation or stool withholding?
*
Yes
No
Unsure
Group Suitability
Can your child participate in a small group for 45 minutes?
*
Yes
With Support
No
Does your child generally follow simple instructions?
*
Yes
Sometimes
No
Is your child able to follow group instructions with minimal support?
*
Yes
No - requires support
How does your child show signs of dysregulation?
*
Crying
Screaming
Biting
Scratching
Self-harming
Harming others
Does not show signs of dysregulation
Goals
What would you like your child to achieve through this group?
*
Service Information
NDIS Participants: $127 per session
Private Paying: $77 per session
How will services be funded?
*
NDIS Self Managed
NDIS Plan Managed
Private Paying
If applicable:
NDIS Number and Plan Manager
Final Information
How did you hear about us?
*
Submit
Should be Empty: