• HISTORY FORM FOR SLEEP SUPPORT

    Please complete and submit this form at least 24 hours prior to your consultation. Please also complete this in one sitting and on a computer rather than a mobile device.

  • Parent Information

  •  -
  •  -

  • Child Information

  • Date of Birth*
     - -
  • For the child we are discussing, did they arrive on time or early?*
  • Are you and the pediatrician still following an adjusted age?
  • Does your baby have trouble tolerating tummy time (if age appropriate)?*
  • Have you noticed if your baby looks to one side more than the other, has flattening of the back of their head, or tilts their head to one side for long periods of time?*

  • Pediatrician Information

  • Has your pediatrician ruled out medical uses that may be causing or contributing to your child's sleep problems, and have you specifically asked if we can move forward with sleep learning?*

  • I recommend you have this conversation in advance of our meeting.

  • Sleep Habits

  • Are you able to sleep at night when your child is asleep?*
  • Do you experience troubling/scary thoughts?*
  • Does your child use a pacifier, lovey, or suck their fingers/thumb?
  • Is your child able to find and replace this item consistently on their own?
  • Does your child sleep with white noise or music?*
  • Does the room your child sleep in have blackout curtains?*
  •    
  • When you make it as dark as you can, are you still able to read the words on a page? If you are unsure, please find out.*

  • Sleep Environment

  • Are these sleep issues new or ongoing?*
  • Is your child home each day?*

  • Sleep Routine

  • What state is your child in when you place them in their crib/bed and when you step out of the room?

  • Sleep Goals

  • Should be Empty: