Takes a Village Intake Form

Your full name *

Your child's name*

Child's age*

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

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

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

What type of sleep outfit does your child sleep in?

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

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

Does your child use a pacifier to sleep.

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

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

Which personality type best describes your child. 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 child 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 child'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 Takes a Village Parent Education? *

What Package did you choose?*

We will discuss a date to begin after initial intake. Do. you have a date that you would prefer to begin by?

MonthDayYear

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 is for informational purposes only and is 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 seek the advice of your physician with any questions you may have regarding a medical condition or the health and welfare of your child.

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 Sierra Shantz be liable to you for any 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, Sierra Shantz does not assume responsibility for errors, omissions, or contrary interpretation of the subject matter within the consultation. Reliance on any advice given by Sierra Shantz 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 Sierra Shantz either verbally, written or implied remains the property of Takes a Village Parent Education LLC 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 Sierra Shantz/Takes a Village Parent Education LLC is confidential. Any passing of any information to anyone is strictly forbidden and subject to international copyright laws.

Terms and Conditions*

I have read and agree to the terms and conditions

Signature*