Potty Training Assessment | Potty Train Express

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DIY Essentials Potty Training Assessment Form

Parent's First name*

Parent's Last name*

Phone*

Email*

Child's First Name

What is the age & gender of your child?

Our potty training program offers two flexible scheduling options to suit your needs. Please choose between:

Is your child currently attending any childcare, preschool, or daycare? If yes, please specify:

Are there any planned trips or events that might disrupt your child's routine within the next month?

Will there be siblings or other children in the house during potty training sessions?

Which Disney, Pixar, Marvel, or other favorite characters does your child like?

Please tell us about any previous efforts to potty train your child. If this is your first time, please share any concerns you might have.

Which of the following best represent your child's personality?

High Energy

Cautious

Free Spirited

Shy

Eager-To-Please

Who will be assisting with the potty training? (select all that apply)

Parent (s)

Older Sibling

Caregiver

Other

How does your child learn best? (Select all that apply)

Visual (pictures, video)

Auditory (listening to instructions)

Kinesthetic (hands on activities)

Verbal (explaining concepts)

Has your child demonstrated the ability to learn new things through imitation?

Can your child willingly follow simple instructions and accept assistance as needed?

Are there any special needs, behavioral challenges or triggers we should be aware of?

If there is a medical condition that may prevent your child from controlling his/her bladder or bowel, please provide the details.

We are committed to enhancing the lives of children and parents in the Metro Detroit community and beyond. If you have suggestions on how we can better serve our community or just want to say hello, we'd love to hear from you. Thank you for visiting!

Buchi@littletotdepot.com
West Bloomfield, Michigan 48322

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