Toilet Learning Questionnaire

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Help me get to know more about your journey

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Which service are you interested in? *

Detailed Plan

Full Support

必須

Child’s Name *

Child’s Age *

Parent’s Names *

Email Address *

Have you approached toilet learning already? Describe the process: *

What have been the biggest challenges so far?

How is your home environment and/or bathroom set up to support this learning process? *

Is your child wearing diapers or pull-ups?

Have you introduced standing diaper changes into your child’s daily routine? *

Is your child waking up with a dry diaper from bedtime and naps? *

Does your child have the capability to dress and undress themselves?

Are there other children in the household? Younger or older?

Does your child spend any time with other caregivers? *

My child attends daycare

My child has a nanny at home

My child is home with one or both parents

必須

Does your child have any known developmental delays? *

Describe your child’s personality: *

Cranky and fussy often

Happy and mild mannered

Playful and inquisitive

Strong willed and stubborn

Anxious and cannot easily separate from a parent

Easily adaptable and mellow

必須

What is the overall stress level in the home currently? *

Low stress

High stress

What are your goals for your child? *

What are your goals for working with me? *

Are you traveling in the near future? Anything else that might disrupt the ability to keep a consistent routine? *

Are all primary caregivers willing to help the child as they embark on this journey towards independence? *

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