Intake Form

Phone *

Does your child nap? If yes, around what time and for how long? *

At what time does your child typically eat dinner? *

Child's name *

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

At what time does your child typically wake up in the morning? *

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 support for bowel training

First and Last Name: *

City *

At what time does your child go to sleep at night? *

If you are filling this out for more than 1 child, does the sibling(s) demonstrate awareness of bodily functions and for how long does the sibling(s) remain dry?

Address *

Child's age (year and months) *

Please indicate preferred dates for the potty training. *

Email: *

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Intake Form

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Please fill out the Intake Form below so we can advise you on how NYC Potty can best help your family. We will contact you as soon as possible. Thank you!