Your full name
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Your child/baby's full name
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Child/baby's gender
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Child/baby's birthdate
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Email address
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Phone number
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Who are the family members living in the household?
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What is your family's childcare arrangement?
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Home with parent
Home with nanny
Daycare
other
What is your baby/child's current sleep schedule (if any)?
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What does your baby or child's bedtime routine look like?
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Does your baby or child fall asleep independently at bedtime and for naps?
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Yes, always falls asleep independently
Sometimes falls asleep on his/her own
Never falls asleep independently and always needs help
Other
What type of sleep clothing does your child or baby sleep in?
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What does your child's current sleep environment look like?
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If you have a baby or toddler that is breast or bottle feeding, describe how many daily feedings and how many ounces per feeding are given.
How much does your baby or child weigh?
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Does your child/baby use any of the following sleep props to fall asleep, or go back to sleep if they wake during the night? Select all that apply.
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Nursing/bottle feeding to sleep
Rocking to sleep
Bouncing, swaying, rocking
Pacifier
Car or stroller ride
Parent laying with or sitting next to child/baby
Other
Which of these characteristics describes your little one? You may select more than one.
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Happy, easy-going, doesn't mind change
Fussy, cranky, cries a lot
Clingy, anxious, needy
Dislikes loud noises, startles easily, seems easily bothered or overstimulated
Alert, interested, engaged, observant; doesn't want to miss the fun
Other
*If you have a baby under 15 months, please answer this question*. Which of these developmental milestones has your baby accomplished? Select all that apply.
Holding head up when placed on tummy
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
Other
What are some of your child’s interests?
If your baby/child has a medical condition or health problem, please describe it below.
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Is your baby/child taking any medication or supplements? If yes, please list below.
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Does your baby/child snore?
yes
no
sometimes
Which statement best describes how you feel about crying in relation to sleep?
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I don't mind hearing crying
I am ok with some crying
It bothers me greatly when I hear crying
Other
Have you tried any other sleep training methods or programs? If yes, what was your experience?
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What else do you want me to know about the difficulties you've been experiencing with sleep?
Please tell me about your goals for working with a sleep consultant.
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How did you hear about Summit Slumber?
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