Your full name
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Your child's name
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Child's gender
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Child'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/School
other
Is your child potty trained?
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No
Yes
Potty trained during the day, but not at night
What is your child's current sleep schedule (if any)?
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What does your child's bedtime routine look like?
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Does your child fall asleep independently?
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Yes, always falls asleep independently at bedtime and naps
Sometimes goes to sleep on his/her own
Never falls asleep independently at bedtime or for naps
Other
What does your child's current sleep environment look like?
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Does your child 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, car ride, or any other movement
Pacifier
Sleeping next to a caregiver
Other
Which of these characteristics describes your child? You may select more than one.
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Happy, playful, easy-going, doesn't mind change
Cranky, fussy, easily upset
Clingy, anxious, has difficulty with new situations
Strong willed, stubborn, resists change
Easily frustrated or overstimulated; bothered by loud sounds or irritating textures
Highly engaged, observant, and interested
Other
What are some of your child's interests? (favorite things to do, toys, tv shows, books)
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If your child has a medical condition or health problem, please describe it below.
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Does your child snore?
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Yes
No
Occasionally
Is your child taking any medication or supplements? If yes, please list them below.
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Has your child experienced any recent major life events? (For example: major illness or injury, illness or death of a relative or close friend, separation/divorce of parents, new marriage of a parent, new sibling, moving to a new home, loss of a pet, etc.)
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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 should I know about the difficulties you've been experiencing with your child's sleep?
Please tell me about your goals for participating in this coaching program.
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