Mommy & Company Family Health Intake Form

Your full name *

Your baby's name*

Baby's age*

What email address did you use for payment?*

What email address will you be using for the consultation?*

What is your baby's current daytime sleep schedule (if any)?

What does your baby's bedtime routine look like? Skip if you don't have one.

What type of sleep outfit does your baby sleep in?

What does your baby's sleeping arrangement look like? Please be specific.

How many hours does your baby sleep in a 24hr period. (Naps+ Night time sleep)?

Does your baby use a pacifier to sleep.

Yes, and I often have to reinsert it.Yes, but it's not a prop. My baby doesn't mind or cry for it when it falls out.No my baby does not use a pacifier.Other

Does your baby use any sleep props to fall asleep? or back to sleep during the night? Select all that apply.*

Which personality type best describes your baby. You may select more than one.*

Quiet, mellow, laid back, doesn't mind change.Cranky, fussy, rarely in a happy mood.Clingy, anxious, often experiences separation anxiety.Strong willed, stubborn, resists change.Happy, playful, usually in great spirits.Other

Have you tried any other methods or programs?*

What developmental milestones (if any) has your baby accomplished? Select all that apply*

Which statement best describes how you feel about crying?*

I don't mind hearing cryingI don't mind hearing some cryingI cannot hear any crying at allOther

Please provide in detail, any additional information that will help me understand what's going on with your baby's sleep troubles. If you have specific questions you can include them here too. If you forget to add something, no worries, you can always add additional information by emailing me.

How did you hear about Mommy & Company Family Health? *

Did a friend refer you? If yes, please tell me your friends name so that I can give that person credit

Do you want to start the consultation on a particular date? If not, leave today's date and I will begin working on a sleep plan right away. *Keep in mind that once the sleep plan is sent, your consultation begins from that date.

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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 Krisztina Danku-Molnar be liable to you for any claims, losses, injury or damages as a result of reliance on the information provided. All though all attempts have been made to verify the information provided is accurate, Krisztina Danku-Molnar does not assume responsibility for errors, omissions, or contrary interpretation of the subject matter within the consultation. Reliance on any advice given by Krisztina Danku-Molnar 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.

COPYRIGHT NOTICE: The information provided within the consultation may not be reproduced, republished, or transmitted in any form or by any means mechanical or electronic, including photocopying and recording, or by any information storage and retrieval system, without permission.

All information supplied by Krisztina Danku-Molnar either verbally, written or implied remains the property of Mommy & Company Family Health™ at all times. Written permission is required to reproduce, record, publish or advise verbally any details of the provided sleep plan, E-guides, charts, notes, advice offered or consultation transcript or summary in any format whatsoever. This includes but is not limited to any details published on any blogs, forums, or similar boards. Any information supplied by Krisztina Danku-Molnar/Mommy & Company Family Health™ is confidential. Any passing of any information to anyone is strictly forbidden and subject to international copyright laws.

I have read and agree to the terms and conditions

Signature*