Potty Training Anxiety Assessment Form

Potty Training Anxiety Assessment Form
Use this form to assess a child's anxiety, identify common triggers and behaviors, evaluate readiness signs, and determine support needs during potty training.
How often does your child show signs of anxiety or distress related to potty training?
Please rate your child's overall anxiety level about using the potty.
Which of the following situations trigger your child's anxiety? (Select all that apply)
Other

How does your child react when encouraged to use the potty?

Rows	Never	Rarely	Sometimes	Often	Always
Cries or becomes upset
Refuses to enter the bathroom
Clings to parent/caregiver
Verbalizes fears or worries
Attempts to negotiate or delay

How confident do you feel about your child's readiness for potty training?

1
2
3
4
5
1 is Not confident, 5 is Very confident
Which readiness signs has your child shown? (Select all that apply)
Other
How often does your child have accidents during potty training?
What support strategies have you tried to help your child with potty training anxiety? (Select all that apply)
Other
How effective have these support strategies been for your child?

1
2
3
4
5
1 is Not effective, 5 is Very effective
Please share any additional observations or concerns about your child's potty training experience.
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