Confidential Toileting Intake Form — Blackbird Special Education

Name of Parent/Other Contact Person

First Name

Last Name

Phone

(###)

###

####

City

First Name of Toileting Trainee

Age of Toileting Trainee

Does the trainee have any formal diagnosis? (e.g., Autism Spectrum Disorder, Down syndrome, ADHD, etc.)

Please briefly describe the trainee's main mode of communication

ex.: uses a picture exchange system to communicate wants and needs ex.: uses verbal speech; speaks in 2-3 word phrases typically

What is the trainee's typical weekly schedule?

ex.: Attends school Mon-Fri, 9am-3pm, and has speech therapy on Thursdays after school, and swimming lessons Saturday mornings

Will the trainee readily drink liquids, and is it medically safe to drink extra liquids? If so, what liquids does he/she like?

(Sometimes, our toileting interventions include increasing the amount of drinks provided)

If necessary, could the trainee stay home for one week (with all other activies cancelled) in order to focus on toilet training?

Please briefly describe any past toileting attempts.

ex.: In summer of 2020, we had him wear underwear at home and tried sitting him on the toilet about once every 30 minutes to see if he would pee. He did pee a few times in the toilet but ended up having a lot of accidents.

Has the trainee ever had a medical intervention or investigation related to toileting? If so, please describe it.

ex.: Our family doctor has asked us to give her a daily dose of a laxative because of constipation. ex.: A urologist has done an investigation but couldn't find any issues and told us the toileting issue is likely behavioural.

Can you list some of the trainee's very favourite things?

ex.: Watching youtube videos, ice cream, any superhero movies, jumping on the trampoline, talking to her cousins on FaceTime, matchbox cars, magazines, macaroni and cheese, etc., etc.!

Do you know (or can you estimate) how many times the trainee typically urinates in a 24 hour period?

1-2 times

3-5 times

6-9 times

10 times or more

don't know

Do you know (or can you estimate) how many times the trainee typically has bowel movements in a 24-hour period?

1 time

2-3 times

4 times or more

the trainee does not have daily bowel movements

don't know

Please share any additional info about the trainee, his/her toileting history, etc. that you think would be helpful to share.

Thank you for your submission! We will get back to you via email.