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Class Location: Primrose School of Royal Palm Beach Palm Beach County

Info@PottyTrainingSchool.org

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Client Intake Forms

Parents Name

Email Address

“What is your current profession or field of work?” (This helps us better understand the families we serve.)

How did you hear about us? *

Google

Preschool Referral

Pediatrician Referral

Instagran

Tik Tok

Facebook

Parents Last Name

Phone

“Which income range best describes your household? (We use this anonymously to improve services.) *

$60,000–$150,000

$151,000–$250,000

$251,000-$350,000

$351,000-$450,000

$451,000-$550,000

$550,000+

“To help us better understand the age range of the parents we serve and tailor our outreach, please share your birth year (YYYY):” (This is used only for internal program development.)

Child's Name

Child's Date of Birth

Preschool

Pediatrician

Is your child taking any medication (murilax, fiber, etc.) *

No

Yes

Is your child in a bed or crib? *

Bed

Crib

If you answered yes, please elaborate

Has your pediatrician cleared your child for potty training? *

No

Yes

Does your child have any special needs? *

No

Yes

If you answered yes, please elaborate

Is your child in any type of OT, PT, or Early Intervention program for a developmental delay? *

No

Yes

If you answered yes, please elaborate

Does your child have any special needs? *

No

Yes

If you answered yes please elaborate

Does your child have constipation issues? *

No

Yes

If you answered yes are you doing anything to help?

I declare that the info I’ve provided is accurate & complete

Medical Release

I agree to the terms & conditions of the Medical Release

Cancellation Policy

I agree to the terms & conditions of th Cancellation Policy

Ditch the Diaper Agreement

I agree to the terms & conditions of the Ditch the Diaper Agreemnt

Non Disclosure

I agree to the terms & conditions of the Non Disclosure

Your Signature

Select a date

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*

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HERE TO HELP

Info@PottyTrainingSchool.org
561-331-6205

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Potty Training School is a comprehensive 4-hour class designed to help children develop proper voiding habits through simple cognitive-behavioral techniques. Using our engaging, play-based curriculum, we build confidence and motivation in toddlers, ensuring they stay entertained and eager to learn.

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