CKM Feedback Form

CKM Feedback Form:

For those who have used the "Clean Kid Manual", we would definitely like to hear your thoughts and experiences with the protocol. Please complete
the form below.

Dr. Robert W. Collins, PhD, PC
Soiling Solutions®
P. O. Box 293
Spring Lake, MI 49456-0293

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Name: *
E-mail Address: *
Phone Number: *
When did you purchase CKM? *
When did you start using the CKM? *
What is the age of the CKM user? *
Did you follow the CKM exactly? *	Yes No
If you varied from the CKM, how?
Have you tried other Encopresis treatments? *	Yes No
Which treatments have you tried? *
Would you say that the CKM was your final option? *	Yes No
Please tell us about your experiences with the CKM: *


* Required

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