Sleep Assessment Form

Parent #1 Name*

First NameLast Name

Parent #1 Email

example@example.com

Parent #1 Phone Number*

Please enter a valid phone number.

Parent #2 Name

First NameLast Name

Parent #2 Email

example@example.com

Parent #2 Phone Number

Please enter a valid phone number.

Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Child's Name*

First NameLast Name

Child's Birth Date*

MonthDayYear

If your child was born premature, please share their adjusted age

Does your child have any diagnosed medical conditions or any current medical concerns from you and/or your child's pediatrician?*

What is your child's biggest / most impactful sleep struggle?*

How impactful are these sleep struggle(s) on you & your child's day to day life?

On a scale from 1-10 with 1 being not impactful at all and 10 being all-consuming, affects everything we do.

How long has this sleep struggle been going on for?*

Have you tried any sleep training tactics or methods to address this current situation or a past situation? If so, what were they and what was the outcome?

On average, how many hours of total sleep does your child get in a 24-hour period?*

What is your child's current sleep schedule?*

Include wake up, nap times & bedtime with as much detail as possible (e.g., we put him down for bed at 7pm and he typically goes to bed around 8:30pm, in between he....)

What is your child's current bedtime routine?

Please skip if you don't have a set routine. If you do, please include each step in the routine, the duration and the location (e.g. read books for 10 minutes in her room)

What is your child's current sleep & room arrangement?*

What does your child wear to sleep?*

Does your child share a room? If so, with whom? If with siblings, what are their ages?

Does your child require any of the following to fall asleep or back asleep upon waking?

What words best describe your child's personality?*

Easygoing, content & amenable to change in routineStubborn, strong-willed & thrives in a consistent routineClingy, fussy and prefers to be near parents / caregivers at most timesHappy, friendly & activeObservant, calm & "slow to warm"Other

[For Children Under 1]: What developmental milestones has your child accomplished? Please select all that apply

Which statement best applies to you (please note that sleep training does not mean "cry it out" and your child will always be supported throughout the sleep training process)?*

I am ok hearing my child cryI am ok hearing my child cry only in limited quantitiesI am not ok hearing my child cry

Is there any additional information or questions you have for me?

Were you referred by a friend? If so, whom?

TERMS AND CONDITIONS

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

IMPORTANT: Restore Sleep Coaching LLC operates restoresleepcoaching.com (the "Site") and provides certain advice and services (the "Services"). Each time you use the Site or Services, you agree to be bound by these Terms of Use. You acknowledge and agree that your use of the Internet and access to the Site or the Services is solely at your own risk. You also understand that the confidentiality of any communication or material transmitted to or from the Site over the internet cannot be guaranteed. Restore Sleep Coaching LLC is not responsible for the security of any information transmitted to or from the Site or Services.

NOT MEDICAL ADVICE: The site and services are for informational purposes only and do not provide medical advice. The information, content and advice provided on the Site and as part of the Services is for informational purposes only and is not medical advice. You are not establishing a medical professional / patient relationship by accessing or using the Site or Services. The information, content and advice provided by the Site or through the Services is intended for use with healthy children with common sleep issues that are unrelated to medical conditions. The information, content and advice provided is not intended to be, and is not, a substitute for professional medical advice. Always seek the advice of your physician regarding any medical condition or the health and welfare of your baby.

PEDIATRIC APPROVAL: You agree to consult with and obtain approval from your pediatrician prior to following any advice or using any techniques offered on the Site or through use of the Services.

LIMITATION OF LIABILITY: Reliance on the information, content and advice offered on the Site and through the services is solely at your own risk. NEITHER RESTORE SLEEP COACHING LLC NOR ANY OF THEIR MEMBERS, MANAGERS, OFFICERS, EMPLOYEES, AGENTS OR CONTRACTORS ARE NOT RESPONSIBLE OR LIABLE TO YOU OR ANYONE ELSE FOR ANY LOSS OR INJURY OR ANY INDIRECT, INCIDENTAL, CONSEQUENTIAL, SPECIAL, EXEMPLARY, PUNITIVE OR OTHER DAMAGES UNDER ANY CONTRACT, NEGLIGENCE, STRICT LIABILITY OR OTHER THEORY ARISING OUT OF OR RELATING IN ANY WAY TO (i) THE USE OR INABILITY TO USE THE SITE AND/OR THE SERVICES; (ii) ANY CONTENT CONTAINED ON THE SITE AND/OR THE SERVICES; (iii) STATEMENTS OR CONDUCT POSTED OR MADE PUBLICLY AVAILABLE ON THE SITE AND/OR THE SERVICES; OR (iv) ANY PRODUCT OR SERVICE PURCHASED OR OBTAINED THROUGH THE SITE OR THE SERVICES. IN NO EVENT SHALL RESTORE SLEEP COACHING LLC BE LIABLE TO YOU FOR ANY CLAIMS, DAMAGES, INJURIES, LOSSES OR EXPENSES FOR USING THE SITE AND THE SERVICES.

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

COPYRIGHT NOTICE: The information and content provided on the Site and through the Services may not be reproduced, republished or transmitted in any form or by any means, whether mechanical or electronic, including photocopying and recording, or by any information storage or retrieval system, without the approval of Restore Sleep Coaching LLC. All information and content provided on the Site or through the Services, either verbally, written or implied, remains the sole and exclusive property of Restore Sleep Coaching LLC at all times. Written permission of Restore Sleep Coaching LLC is required to reproduce, record, publish or share verbally any content (including, without limitation, any sleep plan or advice). All information and content provided or offered on the Site or through the Services is confidential. Any dissemination or sharing of such information or content is strictly forbidden.

DISCLAIMER REGARDING LINKED THIRD PARTY SITES: Links on the Site and/or the Services may direct you outside the Site or the Services in order to access a linked third party site (the “Linked Sites). Restore Sleep Coaching LLC provides these links as a convenience, but we neither control nor endorse these Linked Sites, nor has Restore Sleep Coaching LLC reviewed or approved the content which appears on the Linked Sites. Restore Sleep Coaching LLC is not responsible for the legality, accuracy or appropriateness of any content, advertising, products, services or other materials on or available from any Linked Site.

THIRD PARTY CONTENT: Any opinions, advice, statements, services, advertisements, offers or other information or content expressed or made available through the Site or Services by third parties are those of the respective authors or distributors and not Restore Sleep Coaching LLC. Restore Sleep Coaching LLC does not guarantee the accuracy, completeness, or usefulness of any third-party content. Furthermore, Restore Sleep Coaching LLC does not endorse and is not responsible for the accuracy and reliability of any opinion, advice or statement made on the Site or Services by anyone other than an authorized Restore Sleep Coaching LLC representative. We take no responsibility for your exposure to third party content on the Site or the Services.

CONFIDENTIALITY: Restore Sleep Coaching LLC agrees to keep all conversations and information with and from their Clients confidential, as allowable by law. No personal information will be shared with anyone with your express permission. This clause does not apply if there is an imminent threat of serious injury to you, your baby or someone else.

GENERAL: These terms shall be governed by, and interpreted in accordance with the laws of the state of California. Restore Sleep Coaching LLC reserves the right to amend or modify these terms of use at any time.

Terms & Conditions Signature

Thank you for sharing all of the information above and for taking the first step to improve your child's sleep through sleep coaching!

I'll review all of the information submitted and begin working ASAP on your child's sleep plan. This typically takes 2-3 days on average, but please let me know above if you have any specific timing considerations. Your package will start on the day that your sleep plan is sent. I'm looking forward to working with you!