Free Bedwetting Solution Consultation - We Help Stop Bed Wetting!

This is the first step to a successful treatment.

We ask you and your child (depending on age) to answer the following questions in our Consultation Report. We use this information to counsel you on your bed wetting situation and, if appropriate, to modify the ScoreBoard Treatment Program if you decide to use our services.

After you submit the Consultation Report below, you may want to call us at (281) 298-2888 to talk over your child's situation. We welcome your call but our phone lines are very busy so we suggest that you email your questions to us. We will reply to your questions and give you the written answers to explain to your spouse or caretaker. We cannot discuss with you the entire treatment unless you buy the program. There is never any fee or obligation for counseling - whether you select our services or not.

Also, when you submit this Consultation Form, you will receive an email for the next step in assuring a successful bed wetting treatment.

CONSULTATION REQUEST
SUBMISSION OF THIS FORM IS FREE

R = Required Information

Family Name	R
Email
Street	R
City	R
State	R Province, etc.
Country	R
Zip or Postal Code	R
Phone	R
Fax

TO THE PARENT:
Are you a HUSBAND / WIFE Team ? Or a SINGLE PARENT ?
If you are a single parent, would both parents cooperate in the program ? YES NO
How many children are in the family ?
Do any other members experience bed wetting ? NO YES
Has your child wet since infancy ? YES NO
What is the frequency of bed wetting ? 7 = 1 Week 7 x 7 4-5 x 7 1-2 x 7 1 x 7 Sporadic
If SPORADIC - Please Explain
Do you think your child is a deep sleeper ? YES NO
How is your child's health ?
Is your child taking any medication or drugs ? NO YES
If YES Please Explain
Is your child wearing pullups ? NO YES
Is the child a boy or girl? BOY GIRL
If your child is school age - Does your child have any social problems ? NO YES
Would you be willing to comply with all directions provided by the "ScoreBoard" program to assist your child in becoming dry, ending their bedwetting, such as completing and mailing a semi weekly report (forms provided) ? YES NO
Do you think your child will cooperate ? YES NO

TO THE CHILD:
What is your name ?
Age ? School Grade ?
Do you REALLY want to be dry ? YES NO
Would you become part of a team with your parents and your "ScoreBoard" coach ? YES NO
Would you be willing to drink 6 to 8 oz. of water every night after dinner and before bedtime ? YES NO
Would you be willing to give up things you now eat and / or drink if we asked you ? YES NO
How would YOU feel to wake up in a dry bed, every morning ? Would it be worth all of this to you to stop your bedwetting? YES NO

Please list your favorite and
most frequently eaten foods and beverages

Example	BREAKFAST ... FOOD = Oatmeal, Cereal & Milk, Toast ...
	BREAKFAST ... BEVERAGE = Orange Juice, Hot Milk with Cocoa ...

Food

Beverage

Breakfast

Morning Snack

Lunch

Afternoon Snack

Dinner

Bedtime Snack

What liquids do you consume most during the day ?

Would the entire family be supportive and form a team effort ?
YES NO

Please use this area for any additional details needed.

Name of Parent filling out this form

If you found our site via a search on a search engine, please tell us what search phrase you used and what search engine was used. This will greatly assist us in getting the word out of our great bed wetting program to many others. Thanks!
Search Phrase: Search Engine:

This email was created using the AWeber Support System

Idea - you may want to print this form after you have completed it and before submitting so that you have a copy for yourself. This will be useful if you call us or use our services.

All information is held strictly confidential.
SUBMISSION OF THIS FORM IS FREE

Enuresis can be cured! Stop your child's bed wetting - call us today! We cure enuresis in six to eight weeks!

Helpful Links