Pre-Visit Information Form (Confidential)

Our goal is to make the toilet learning experience as enjoyable and comfortable as possible for your child (and the rest of your family!). Please share any information that may be helpful.

Name of parent

First Name

Last Name

Cell phone number

(###)

###

####

First name of toileting learner

Home address

Is there anything we should know about parking at your home?

e.g., please don’t park in the driveway, you’ll need a parking pass from us, our guest spot is number 6, etc.

Please list anyone else who may be present at home and their relationship to the learner:

e.g. Jim (dad), Maya (2-year-old sister), Lin (grandmother) etc.

What are your child’s favourite activities at home?

e.g., jumping on the trampoline on patio, watching TV on living room couch, painting at kitchen table, having a bubble bath, etc.

What are some signs your child is having fun, and/or enjoying him/herself?

e.g., smiling, will sit/stand close to you, make a contented clicking noise with tongue, etc.

What are some signs your child is NOT enjoying him/herself, and/or is no longer enjoying engaging in learning?

e.g., will try to leave area, may hit others, cry, etc.

If your child becomes upset, are there any strategies you've found are useful for helping them feel calm and regulated?

e.g., a hug from a parent, accessing the swings outside, listening to music

Is there anything you’ve noticed that’s generally triggering/upsetting for your child?

e.g., sudden loud noise (like a fire alarm), giving up access to a favourite item, upset when a particular relative leaves the house, etc.

Does your child ever nap at home? If so, what time?

Are there any medical concerns we should know about?

e.g., seizures, allergies, medication needs

Is there anything we should know about the learner's communication that might be helpful for us to know about in advance?

e.g., he says "sippy" when he wants milk; she does a waving gesture when she's requesting water play, etc.

Do you have any important "house rules" we should know about?

e.g., no food in the living room, please don't go upstairs, typically prefer a maximum of 1 hour screen time daily, etc.

Is there anything else we should know about being in your home to make the experience as comfortable as possible for your family?

e.g., please wear a mask, please be careful opening the door so our cat won’t get out, etc.

Is there anything else you can think to add that our team members should know to best support the learner?

Pre-Visit Information Form (Confidential)

How can we help?

Blackbird Toileting Services

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