Potty Training Intake Form | Mama Bear Sleep Co

First name

Last name

Email

Phone

Child's Name

Child's Age

Child's Birthdate

What are you goals in working together?

What readiness signs is your child showing (if any)

18+ months old

Interested in the potty

Can communicate potty words

Can pull pants up and down (not buttons or zippers)

Has a dry diaper for 2 hours

Hides to go #1 or #2 in their diaper

Comes to tell you after they have done #1 or #2

What stage of potty training are you in?

Is there any other information that you think is important for me to know?

Date you would like to support to begin.

Where did you find Mama Bear Sleep Consulting?

TERMS AND CONDITIONS  BY SIGNING BELOW YOU AGREE TO THE FOLLOWING TERMS AND CONDITIONS: 

 MEDICAL DISCLAIMER: The information/advice provided during this consultation is not medical advice. You are not establishing a medical professional/patient relationship. The information provided is not intended nor is implied to be a substitute for professional medical advice. Always seek the advice of your physician with any questions you may have regarding a medical condition or the health and welfare of your baby. 

PEDIATRICIAN APPROVAL: You agree to consult with and get approval from your pediatrician before following the advice or using the techniques offered during this consultation.  

LEGAL NOTICE: In no event will Mama Bear Sleep Consulting be liable to you for any claims, losses, injury or damages as a result of reliance on the information provided. Although all attempts have been made to verify the information provided is accurate, Mama Bear Sleep Consulting does not assume responsibility for errors, omissions, or contrary interpretation of the subject matter within the consultation. Reliance on any advice given by Mama Bear Sleep Consulting is solely at your own risk. 

REFUND POLICY: Due to the amount of time, effort, and commitment provided within a consultation, refunds are not possible once this form is submitted.  

COPYRIGHT NOTICE: The information provided within the consultation may not be reproduced, republished, or transmitted in any form or by any means mechanical or electronic, including photocopying and recording, or by any information storage and retrieval system, without permission. All information supplied by Mama Bear Sleep Consulting either verbally, written or implied remains the property of Mama Bear Sleep Consulting at all times. Written permission is required to reproduce, record, publish or advise verbally any details of the provided sleep plan, E-guides, charts, notes, advice offered or consultation transcript or summary in any format whatsoever. This includes but is not limited to any details published on any blogs, forums, or similar boards. Any information supplied by Mama Bear Sleep Consulting is confidential. Any passing of any information to anyone is strictly forbidden and subject to international copyright laws.  

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