Questionnaire

Your full name *

Your baby's name*

Baby's age*

Baby's date of birth*

Date

What email address did you use for payment?*

What email address will you be using for the consultation?*

What is your baby's current daytime sleep schedule (if any)?

What does your baby's bedtime routine look like? Skip if you don't have one.

What type of sleep outfit does your baby sleep in?

What does your baby's sleeping arrangement look like? Please be specific.

How many hours does your baby sleep in a 24hr period. (Naps+ Night time sleep)?

Does your baby use a pacifier to sleep.

Yes, and I often have to reinsert it.Yes, but it's not a prop. My baby doesn't mind or cry for it when it falls out.No my baby does not use a pacifier.Other

Does your baby use any sleep props to fall asleep? or back to sleep during the night? Select all that apply.*

How is your baby currently getting his/her nutrition. Select all that apply. (Please note all feeding instructions should be handled by your pediatrician or health advisor)*

BreastfeedingFormulaSolidsOther

Which personality type best describes your baby. You may select more than one.*

Quiet, mellow, laid back, doesn't mind change.Cranky, fussy, rarely in a happy mood.Clingy, anxious, often experiences separation anxiety.Strong willed, stubborn, resists change.Happy, playful, usually in great spirits.Other

Have you tried any other methods or programs?*

What developmental milestones (if any) has your baby accomplished? Select all that apply*

Which statement best describes how you feel about crying?*

I don't mind hearing cryingI don't mind hearing some cryingI cannot hear any crying at allOther

Please provide in detail, any additional information that will help me understand what's going on with your baby's sleep troubles. If you have specific questions you can include them here too. If you forget to add something, no worries, you can always add additional information by emailing me.

How did you hear about Serene Baby Sleep Consulting?*

Did a friend refer you? If yes, please tell me your friends name so that I can give that person credit

Do you want to start the consultation on a particular date? If not, leave today's date and I will begin working on a sleep plan right away. *Keep in mind that once the sleep plan is sent, your consultation begins from that date.

Date

TERMS AND CONDITIONS

BY SIGNING BELOW YOU AGREE TO THE FOLLOWING TERMS AND CONDITIONS:

MEDICAL DISCLAIMER:

The information/ advice provided during this consultation is not medical advice. You are not establishing a medical professional/patient relationship. The advice and content are for informational purposes only and are intended for use with healthy children with common sleep issues that are unrelated to medical conditions. The information provided is not intended nor is
implied to be a substitute for professional medical advice. Always see the advice of your physician or your child’s pediatrician with any questions you may have regarding a medical condition or the health and welfare of your baby.

PEDIATRICIAN APPROVAL:
You agree to check with your pediatrician and get their approval before following the advice or using the techniques offered during this consultation.

LEGAL NOTICE:
In no event will Serene Baby Sleep Consulting, LLC be liable to you for any direct or indirect claims, losses, injury or damages as a result of reliance on the information provided. All though all attempts have been made to verify the information provided is accurate, Serene Baby Sleep
Consulting, LLC does not assume responsibility for errors, omissions, typography, or contrary interpretation of the subject matter within the consultation. Reliance on any advice given by Serene Baby Sleep Consulting, LLC is solely at your own risk.

REFUND POLICY:
Your satisfaction with Serene Baby Sleep Consulting, LLC is important to us. However, due to the amount of time, effort, preparation and commitment provided within and during a consultation, refunds are not possible.

COPYRIGHT NOTICE:
The information provided within the consultation may not be republished, redistributed, reproduced, transmitted and or changed in any way or by any means mechanical or electronic, including photocopying and recording, or by any information storage and retrieval system,
without authorization written by Serene Baby Sleep Consulting, LLC. All information provided by Serene Baby Sleep Consulting, LLC either verbally, written, or implied remains the property of Serene Baby Sleep Consulting, LLC at all times. Written authorization is required to reproduce, record, publish or advise verbally any details of the provided sleep plan, e-guides, charts, notes, recommendations and advice offered, or consultation transcript or summary in any format whatsoever. This includes but not limited to any details published on any blogs, forums, or similar boards.
Any information provided by Serene Baby Sleep Consulting, LLC is confidential. Any passing of any information provided by Serene Baby Sleep Consulting, LLC to anyone is strictly forbidden and subject to international copyright laws

I have read and agree to the terms and conditions

Signature*