Fox and The Moon Infant Sleep Services
New Customer Form
Name of Child
Name, Age's of Any Siblings:
Where did you hear about Fox & The Moon Infant Sleep?
What day of the week and time would you like to speak?
Is there anything you need me to know so I can be respectful of your family and situation? If no, please N/A
Background History and Health
Do you have any health concerns regarding your child? If yes, what?
Is your child taking any prescribed or over the counter mediction?
Who looks after your child during the day?
Are there any concerns regarding your child's weight?
Does your child have any skin issues?
Does your child have a history of tongue tie?
Does your child regularly mouthbreathe/snore/have noisy breathing?
Does your baby suffer from reflux?
If yes, or has in the past please email me email@example.com so we can chat before we start
If applicable, does your child have breastmilk or formula? Or a combination?
Does your child use a dummy?
Were there any complications with your child's birth and how was your child born? (ventouse, c section, unassisted vaginal delivery)
Is there a family history of allergies, food intolerances, eczema or asthma?
Is your child under any health professional or care team?
Your Current Sleep Situation
How do you get your child to sleep currently?
Do you have a bedtime routine? If so, what is it?
Please detail the sleep your child has during the day, nap timings and lengths?
Where does your child sleep? Cot, bed, in your bed etc
Is there anything you definitely DO NOT want to change?
What is the thing you most like to change and you'd like us to prioritise?
How would you describe your parenting style?
How would you scale your current sleep situation?
I just need some reassurance
I know my child's sleep is normal, but I'm beginning to struggle and need some support. I do not really feel I need to change my child's sleep, it's more how I manage on a day to day basis
I'm beginning to find my child's sleep problematic, and need to find some ways to make it easier. I am prepared to make some changes, but do not feel this is an emergency situation, and I can take my time.
I am in a sleep crisis. I feel like I cannot go on much longer, and urgently need to make some changes. I may not know where to start, and I may not have the capacity for anything that results in even less sleep, but I definitely need to make some big changes in order to cope.
Your Child's Eating Habits
Please fill in your child's approximate meals/feed timings in 24 hours
Is your child generally a good eater?
What are your main sleep concerns?
What are your specific sleep goals?
What package do you think you will require?
Full Support Package, sleep plan of action and 2 weeks of WhatsApp Support £300
Sleep Plan of Action with a week of email support £170
Phone Consultation £40
I am not sure yet and would like to discuss further
Are you happy to be added to my mailing list for sleep tips and discounts?
I require my clients to fill out a 3 day/night sleep diary. You can submit the form without this information but I would encourage you to start keeping note of the following so I can help you quicker. Time woke in the AM | Time and length of naps in the day | Time start preparation for bed in the evening | Time went to sleep | Who put to bed? | Time woke in the night | What happened and what did you do? |
( X )
A 45-minute phone call that you may want to take for small sleep problems that you would like to chat through these might be: Early mornings Nap resistance or timings Or simply a reassurance call to make sure you are on the right track
The Badger Package
his involves a phone consultation where we talk at length about the details you submit on your ‘new customer form’ we will talk about your sleep goals, your family life and your normal day to day routines to make sure the gentle and holistic sleep plan I produce fits in with that as much as possible. I then go and write a comprehensive sleep plan and email it to you to action. You will then have one point of contact a day via email that you will initiate, you will give me updates and talk through any challenges and I will be able to guide you
The Fox Package
This involves all that the Badger package includes, but with an additional two weeks of support, from 8am – 8pm. I prefer this to be done over WhatsApp where possible, you can message me an unlimited number of times during these two weeks and I can help virtually support at nap-times and at bedtimes and help with any curve balls! This is essential if you feel like you would benefit from the moral support, the expert advice in real time and the reassurance you are doing the right thing!
“I can’t go to sleep yet, I need one more story” “I am bored” “I don’t need sleep, I am not tired” “I need another wee” sound familiar? I can help, whether your toddler (3-6 years) is making up the most amazing bedtime stalling excuses, you are co sleeping and wish to transition your child into their own bed/room or you are struggling with night terrors then this is the package for you. This includes, a phone consultation, a personalized and comprehensive sleep plan and 2 weeks of Whatsapp support. Feel free to book a free phone consultation for us to discuss your needs in more detail and what level of support you would benefit from.
Debit or Credit Card
Credit Card Number
Please click one of the PayPal options to complete payment and
Should be Empty: