Rise Pediatric Consulting Intake Form

Parent Name

First NameLast Name

Child Name

First NameLast Name

Child's Birth Date

Date

Child's Estimated Due Date (if born premature)

Date

Address

Street Address

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Email

What goals would you like to set for your child's sleep?

What are your biggest challenges regarding your little one's sleep?

What time are your child's naps and how long are they (on average?)

Skip if your child no longer naps

Does your child have a bedtime routine?

What time does your child usually go to bed?

How many times does your child usually wake in the night? How do you usually respond to these wakings?

Please include number of night feedings, if applicable.

What time does your child wake up for the day?

Does your child have any health issues or developmental delays I should be aware of?

Sleep Environment

	Yes	No
Does your child have their own room?
Does your child sleep in a crib?
Does your child sleep with a sound machine?
Does your child nap with blackout curtains?
Do you want to bed-share?*

Does your child regularly use any of the following to fall asleep?

Feeding to sleepIn bed with Mom/DadBeing held or rocked to sleepOther

I place my child down:

AwakeDrowsyAsleep

Does your child use a pacifier for sleep?

Yes, and it causes problemsYes, but it isn't a problemNo pacifier

Has your child had a new developmental milestone in the past 2 weeks? (rolling, crawling, walking, talking, etc.?)

YesNo

How would you rate your "cry tolerance?"

HighMediumLowNone

Is there any additional information about you, your child, or your family that you would like me to know so that I can better support you?

Which service would you like to purchase?

Enter discount code here:

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 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 Rise Pediatric Consulting 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, Rise Pediatric Consulting does not assume responsibility for errors, omissions, or contrary interpretation of the subject matter within the consultation. Reliance on any advice given by Rise Pediatric Consulting 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.
CONFIDENTIALITY NOTICE: Any information supplied by Rise Pediatric Consulting is confidential. All information shared with Rise Pediatric Consulting will remain confidential.

Date

Client Signature

Rise Pediatric Consulting

Release and Acknowledgement