Welcome to Belgrade Behavior
Behavior is a process...it is changing, f
Name of Child
Name of Person Filling out Questionnaire
Contact Telephone Number
Is your child wearing underwear?
How long does your child stay dry?
Does your child ever wake up dry?
If so, how often?
Does your child drink liquids adequately?
What will (s)he drink?
Has your child ever sat on the potty?
If so, urine or feces?
Does your child experience constipation?
Does your child have frequent soft stool or diarrhea?
Does your child dress him/herself?
Does your child respond to his/her name?
Specify if only with familiar people
Does your child follow simple directions as part of a familiar routine?
Will your child follow a concrete direction out of context? For example, put shoes in a box for storage
Does your child enjoy a variety of items/activities?
Please list a variety of items/activities your child enjoys
Will your child comply/work for a specified reward? For example: when told "First put your cup in the sink and then you may have the cookie, your child will put the cup in the sink
Does your child associate items with events? For example, a cup= drink; shoes on= going outside
Does your child demonstrate preferences?
Does your child have a method of communicating wants/needs?
If so, what is your child's means of communication?
Please list any medical problems your child has:
Please list any medications your child is taking:
Please list types of therapy your child is receiving:
Please tell us any special information you want to share that you feel will help us potty train him/her:
Has your physician approved of your child receiving potty training?
Thank you for contacting us. We will get back to you as soon as possible
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