Go Diaper Free DFW - Client Intake Form Question Title * 1. Contact Information Name Address Address 2 City State ZIP Email Address Phone Number Question Title * 2. Which service are you interested in? Building Blocks Package (1 Hour of In-Home Consultation and 2 Follow Up Emails) Ready Set Potty Package (2 Hours of In-Home Consultation, 1 30 min Q&A Call, and 2 Follow Up Emails) VIP Journey to Potty Independence Package (4 Hours of In-Home Consultation, 2 30 min Q&A Calls, and 4 Follow Up Emails) Support Call (30 min Call and 1 Follow Up Email) Other (please specify) Question Title * 3. How old is your child? Years Months Question Title * 4. Have you previously tried to potty train this child? Yes No If yes, please specify which methods you used and what the challenges were Question Title * 5. Do you have other children? Yes No If yes, please specify ages Question Title * 6. For previous children, what was your experience with potty training? Question Title * 7. What are your concerns and/or fears with the potty learning process? Question Title * 8. What types of food does your child typically eat? Question Title * 9. What types of fluids does your child drink? (Check all that apply) Breast Milk Cow's Whole Milk Cow's 2% Milk Cow's Skim Milk Goat's Milk Fruit Juice Water Question Title * 10. Does your child have any food allergies or sensitivities? Yes No If yes, please specify Question Title * 11. Does your child have constipation? Never Sometimes Frequently I don't know Question Title * 12. Which term best describes your family's diet? Standard American Diet (packaged foods, high carb) Low Fat Whole Foods/Weston A. Price Paleo Other (please specify) Question Title * 13. What type of diaper has your child been wearing? Disposable Cloth Cloth and Disposable Question Title * 14. Where does your child typically spend his/her day? Day Care/Pre-School At home with parent or other caregiver Other (please specify) Question Title * 15. Please select your preferred appointment day. The time will be agreed upon via email. Weekdays after 7pm Monday,Wednesday,Friday 10am to 1pm Saturday 10am to 8pm Sunday 2pm to 8pm Question Title * 16. Coupon Code or Name of Referring Party Question Title * 17. Appointments will not be confirmed until payment is received. All payments must be received 24 hours prior to the scheduled appointment unless otherwise agreed (Google Wallet, Paypal, Venmo, check, cash). You may reschedule your appointment with 24 hours notice one time. All other reschedules will incur a $15 rescheduling fee. Additional travel fees will occur for locations more than 30 miles from the Irving Convention Center ($2.50/extra mile). I agree to the terms Question Title Done