Sleep Intake

Intake form and terms and conditions for sleep services

Please complete the questions as best you can. If you forget to add something, no worries, you can always add additional information by emailing me.
Full Name*

First NameLast Name
Phone Number*
E-mail*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your child's name:*
Child's Date of Birth*

MonthDayYear
Date
What is your baby's current daytime sleep schedule (if any)?
Example: Wake up 7 am, Nap #1 11-12, Nap #2 3-4, Bedtime 8 pm
What does your baby's bedtime routine look like?
Skip if you don't have one. Example: Bath, Pjs, read a book, feed, sleep then rock to sleep
What type of sleep outfit does your baby sleep in?
Example: Pjs and swaddle
What does your baby's sleeping arrangement look like? Please be specific.
Example: baby sleeps in own crib in own room no siblings or baby sleeps in bassinet in parent’s room on mom’s side of bed.
How many hours does your baby sleep in a 24hr period. (Naps+ Night time sleep)?
Does your baby use a pacifier to sleep?

YesNo
Does your baby use any sleep props to fall asleep? or back to sleep during the night?

Nursing to sleepBottle to sleepRocking to sleepBouncing, swaying, or any other movementMy baby does not use any props to fall asleep at bedtime or during the nightOther
Which personality type best describes your baby?

Quiet, mellow, laid back, doesn't mind changeCranky, fussy, rarely in a happy moodClingy, anxious, often experiences separation anxietyStrong willed, stubborn, resists changeHappy, playful, usually in great spirits
What developmental milestones (if any) has your baby accomplished?

None yetHolding head up when placed on bellyRolling onto sideRolling from belly to backRolling from back to bellySitting, but can't lay back downSitting, and knows how to lay back downCrawlingStanding, but can't sit back downStanding, and knows how to sit back downWalking
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 all
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 Graceful Beginnings? *
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 information provided is not intended nor is implied to be a substitute for professional medical advice. Always seek the advice of your physician with any questions you may have regarding a medical condition or the health and welfare of your baby. 

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

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

REFUND POLICY: Due to the amount of time, effort, and commitment provided within a consultation, refunds are not possible once this form is submitted.  

COPYRIGHT NOTICE: The information provided within the consultation may not be reproduced, republished, or transmitted in any form or by any means mechanical or electronic, including photocopying and recording, or by any information storage and retrieval system, without permission. All information supplied by Graceful Beginnings either verbally, written or implied remains the property of Graceful Beginnings at all times. Written permission is required to reproduce, record, publish or advise verbally any details of the provided sleep plan, E-guides, charts, notes, advice offered or consultation transcript or summary in any format whatsoever. This includes but is not limited to any details published on any blogs, forums, or similar boards. Any information supplied by Graceful Beginnings is confidential. Any passing of any information to anyone is strictly forbidden and subject to international copyright laws.  
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Intake form and terms and conditions for sleep services