Sleep Consultation Intake Form

Please fill out the form below with as much detail as possible

Parent Name(s)

Address

Email

example@example.com

Phone

Include area codeFormat: (000) 000-0000.

1. Who lives in your home? Do you have any pets?

2. Please list all your children (names, ages.)

Please provide information about the child we will be helping.

Child's Name

DOB

Due Date

3. Does your child have any medical issues we should be aware of? Take medications (prescription and non-prescription including supplements) Please list all.

4. Does your child snore or mouth breathe?

5. Is your child in daycare or school?

6. Who is their primary caretaker? Who spends the most time with them? Who is putting them to sleep (nap, bedtime)?

7. What time do they wake for the day? How do they wake up? Are they happy or are they cranky when they wake?

8. Does your child nap? If yes, how many times per day and for how long? How do they wake up?

9. What time is bedtime?

10. Please describe your child's bedtime routine in detail.

11. Does your child experience night wakings? If yes, please describe how you handle them (who handles them and what is done to soothe your child).

12. Does your child feed at night? If yes, how many times and when do feeds typically occur?

13. Please describe your child's typical temperament and behavior.

14. Where does your child sleep? (crib, family bed, stroller, car, swing, etc.). Please list all.

15. Please describe the room that your child sleeps in. Be as detailed as possible.

16. Does your child share a room with anyone? Do they sleep with someone else (in the same room or bed)?

17. What is the typical temperature in your child's room? How do you monitor it?

18. What does your child wear when they sleep? Include swaddles or sleep sacks.

19. Do you have curtains/shades on the windows? Are they blackout? Is the room completely dark or is their light coming into the room? Is the bedroom door closed/open?

20. Do you use a sound machine? If yes, what type/where is it located in the room?

21. Does your child have a lovey, blanket, pacifier, or other items they use to fall asleep? Does your child do anything else to help them fall asleep (rubbing, squeezing something, etc.)? If yes, please describe.

22. Does your child sleep with anything in their bed? Please list.

23. When you put your child down to sleep are they awake, drowsy, or already asleep? How do you lay them down (back, stomach, side, etc.)?

24. Please describe your daily schedule below. Include wake time, all feedings, naps, any activities, routines, and bedtime. Be as specific as possible.

19. Do Mom or Dad have a history of depression or anxiety? Postpartum depression or anxiety?

20. Has your family experienced any loss or trauma (recent or in the past)? How was your child affected by this?

21. Have you ever worked with a sleep consultant before? If yes, please describe your experience.

22. Have you read any books/blogs on sleep? If yes, please list.

23. Sleep philosophies you agree or disagree with? If yes, please explain.

24. Will other caretakers follow your child's sleep schedule/routine if you are away or unable to implement it?

25. Are adults in the household committed to your child getting quality sleep? If not, please explain.

26. What are your sleep goals for your child? Short term? Long term?

27. What are your sleep goals for your family? Short term? Long term?

28. Are there are any potential barriers to achieving your goals?

29. Any travel plans or reasons you would be unable to devote 2 full weeks of sleeping at home and sticking to a schedule?

Please share anything you think we should know about your child or family.

Sleep Consultation Intake Form

Family Information

Child Information:

Child's Sleeping Environment:

Parent History and Family Philosophy

Goals for the Child and Family