Client Intake Form
Parent Name
First Name
Last Name
Parent Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Name
Child's Date of Birth
-
Month
-
Day
Year
Date
Parent Occupations
Name of Pediatrician
First Name
Last Name
Pediatrician Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
When are you hoping to start sleep training?
How did you hear about my services?
Names and ages of siblings living at home
Child's current weight and growth percentile if you have it?
Any medical issues I should be aware of (reflux, allergies, etc)?
Was your child born early? If so, how many weeks?
Is your child bottle or breastfed? If so, indicate which or both.
What time does your child typically wake for the day?
Does your child take naps? If yes, indicate number and duration of naps, as well as typical times they occur.
What time is bedtime?
How long does it take for your child to fall asleep?
What does your child's current bedtime routine look like? Indicate if you do not have one
Does your child fall asleep without your help?
Is your child swaddled or wear a sleep sack to sleep?
Does your child wake up throughout the night? If so, frequency and duration of wakings. Also, indicate how you typically respond.
Where does your child sleep (crib, own bed, shared bed, stroller, carseat, etc.)? Indicate any that apply.
What is the level of darkness in your child's main sleep environment?
Completely dark
We use blackout blinds or curtains but some light gets in
I use a nightlight or some sort of lighting in my child's room at night
Bright and sunny
Do you use any kind of white noise? If so, what kind and what is the volume level of noise used?
Do you use a video monitor?
How many hours does your child sleep in a 24hr period. (Naps + Night time sleep)?
Does your child use a pacifier to sleep.
Does your child use any sleep props to fall asleep? or back to sleep during the night? Select all that apply.
Nursing to sleep
Bottle to sleep
Rocking to sleep
Bouncing, swaying, or any other movement
Other- Specify below
Which personality type best describes your baby. You may select more than one.
Clingy, anxious, often experiences separation anxiety
Strong-willed, stubborn, often resists change
Happy, playful, usually in great spirits
Other- Specify below
Have you tried any other methods or programs?
What developmental milestones (if any) has your baby accomplished? Select all that apply
Holding head up when placed on belly
Rolling onto side
Rolling from belly to back
Rolling from back to belly
Sitting, but can't lay back down
Sitting, and knows how to lay back down
Crawling
Standing, but can't sit back down
Standing, and knows how to sit back down
Walking
All of the above milestones
Which statement best describes how you feel about crying?
I don't mind hearing some crying
I don't mind hearing very little crying
I prefer a no-cry approach
Other- Specify below
Are there any sleep philosophies that you agree or disagree with? Explain.
Is everyone in your home committed to your child getting restful sleep? If no, explain.
Is there anything that may hinder progress with sleep training?
How long do you expect sleep training to take?
What are your goals for your child when it comes to sleep?
Please provide in detail, any additional information that will help me understand what's going on with your child's sleep troubles.
Which sleep package are you interested in?
Submit
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