We look forward to serving you! Providing more information upfront allows us to be especially prepared for your consultation. Please note that all required questions are marked with an asterisk (*).

You are welcome to skip any non-required questions, and we can discuss those details during our call if needed.

First Name *

Last Name *

Email *

Please use the same one you used to book your consult)

Phone *

(Just in case we need to reach you if Zoom isn't working. Not applicable for international clients)

Child’s first name (or nickname, whichever you prefer us to use on the call with you) *

I’d like my child referred to as: he, she or other *

Child’s birth month and year (we don’t need the exact date, so feel free to choose “1” for the day of the month) *

Are you located in the United States?

Yes

Street Address *

City *

State *

Country *

Postal code *

Are you the child’s LEGAL guardian (parent, or legal guardian)? We are not able to conduct this consultation unless you are the child’s legal parent, with custodial rights, or legal guardian, or have a written, signed note on file with us. *

Yes

You entered that you are NOT the child’s legal guardian. To clarify, are you the child’s legal guardian?

Yes

Have you previously tried to potty train this child?

Yes

Based on your last answer, which stage would you like most to focus on during our first call? *

Stage 2: Day Training at Home

Stage 3: Day Training Away from Home

Stage 4: Nights & Naps

Stage 5: All By Myself

Based on your previous answer, which stage would you like most to focus on during our first call?

Are there any reasons why you specifically chose not to potty train before now? If so, please describe in the next question. *

Yes

Briefly describe your potty training journey so far:

Which method did you use?

What challenges did you face with your previous potty training attempts?

What is your approximate catch rate for PEE (in the potty 100%) without physically putting your child on the toilet/potty yourself:

Every time (100%)

Every other time (50%)

Every third time (33%)

Not much at all (obviously more misses than catches)

What is your approximate catch rate for POOP (in the potty 100%) without physically putting your child on the toilet/potty yourself:

Every time (100%)

Every other time (50%)

Every third time (33%)

Not much at all (obviously more misses than catches)

What are you potty training fears or concerns?

How does your child typically respond when learning new skills or engaging in structured activities with their primary caregiver? (can choose multiple)

Use this space to describe your choice of other in the previous question.

My child has: (can select more than one) *

Neuro-typical developmental (no special needs)

Special needs (diagnosed)

Special needs (either in-progress of being diagnosed, or a parent-observed area of developmental concern)

Learning Disabilities:

Emotional and Behavioral Disorders: These involve persistent and significant emotional or behavioral problems that adversely affect educational performance. Examples include anxiety disorders, depression, attention-deficit/hyperactivity disorder (ADHD), and conduct disorders.

Dyslexia (reading), Dysgraphia (writing)

Dyscalculia (math)

Autism Spectrum Disorder (ASD): This is a complex developmental condition that affects communication and behavior. It is characterized by challenges with social interaction, communication (both verbal and non-verbal), and restricted or repetitive behaviors.

Speech and Language Impairments: This category includes difficulties with verbal communication, such as articulation disorders (trouble making sounds), fluency disorders (stuttering), voice disorders, and language disorders (difficulty understanding or using spoken or written language).

Physical Disabilities: This covers a wide range of conditions that limit a person's physical mobility or dexterity. Examples include Cerebral Palsy, Spina Bifida, Muscular Dystrophy, and amputations.

Sensory Impairments:

Visual Impairment: Ranging from partial sight to blindness. Hearing Impairment: Ranging from partial hearing loss to deafness.

Sensory Processing Disorder (SPD): While sometimes categorized under neurological disorders, SPD specifically refers to difficulties in processing sensory information (sight, sound, touch, taste, smell, movement, balance) from the body and environment.

Other Health Impairments: This is a broad category that includes chronic or acute health problems that limit strength, vitality, or alertness, affecting a child's educational performance. Examples include ADHD (often placed here or under emotional/behavioral), diabetes, epilepsy, asthma, heart conditions, and chronic fatigue.

Please use this space to describe your child's special needs (include things such as developmental delays including how it affects daily life regarding needs in terms of physical, social, emotional, speech, diagnosis, syndrome or disease) *

How did you hear about The Potty School? *

Please elaborate - either a name, podcast or other

Is your child currently under the care of:

Behavioral Therapist (e.g., Applied Behavior Analysis - ABA Therapists, Board Certified Behavior Analyst - BCBA)

Counselors/Therapist (General Mental Health)

Educational Therapist (ET)

Occupational Therapist (OT)

Physical Therapist (PT)

Psychologist (School Psychologist or Educational Psychologist)

Recreational Therapist

Speech-Language Pathologists (SLP)

Do you have other children?

Yes - Older

Yes - Younger

Yes - On the Way (pregnancy, surrogacy, adoption, foster, etc.)

Potty Training Supplies & Environment

Please share information about the potty training supplies you're currently using or have tried. This helps us understand your setup and tailor our suggestions for the most effective approach.

What type of potty chair or toilet seat are you currently using?

What kind of underwear or pull-ups is your child typically wearing during the day?

What kind of underwear or pull-ons is your child typically wearing at night/naptime?

Does your child have easy access to the potty in different areas of your home (e.g., bedroom, playroom)?

Yes

Have you used any other tools or resources?

Reward charts

Timer

Special books

Apps

Is there anything about your bathroom environment (e.g., lighting, noise, toilet flushing) that seems to bother your child?

Yes

What is it about the bathroom environment that bothers your child?

If you magically could, what do you wish you could change about your demeanor during potty training?

Is there anything else we should know before our consultation? *

Our consultations are designed for one primary client and one additional adult attendee, for a total of two participants per session. Should you require additional attendees, an extra consultation fee will apply. Email [email protected] for current adult add-on rates.

Yes

Are you a registered Strong Families®, Safe Families®, foster family, or adoptive parent to this child? If you don’t understand what this question is asking, answer NO.

Yes

We don’t advertise it, but we SUPER support you! In fact, our CEO’s family has been volunteering for over a decade hosting children through both the Safe Families and Strong Families programs over the years. We would like to offer you 3-months of our Diapers-to-Flush membership, free of charge, no recurring fees, no credit card needed. After you complete this in-take questionnaire, please email our CEO, [email protected] with the exact subject line “Host/Adoptive/Foster Family Complimentary Diapers to Flush Request”.

Thanks for answering! AFTER you press “submit” you answers will be routed to The Potty School consultant whose expertise best aligns with your family's needs. You should have already received a confirmation email with all the details for your scheduled consultation, including your booking time and Zoom/call link. If you selected a phone consultation, your consultant will call you at the number you provided during booking.

If you have questions, feel free to reach out to: [email protected]

We're looking forward to connecting soon!

Our consultations are designed for one primary client and one additional adult attendee, for a total of two participants per session. Should you require additional attendees, an extra consultation fee will apply. You may contact [email protected] at least 24-hours in advance for assistance adding an additional attendee.

Yes, I agree

Do you consent to receive email communications from The Potty School® regarding potty training tips, course updates, special offers, and new resources? You may opt-out at any time. You will receive communication about your consultation no matter your answer below.

Yes

By proceeding with booking, you acknowledge and agree that your consultation will be conducted virtually via video chat or via telephone, as selected during the scheduling process. *

Yes