Baby Sleep Intake Form

Your full name

Your baby's name

Baby's age

Baby's date of birth

Date

What email address will you be using for the consultation?

What phone number 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?

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

How is your baby currently getting his/her nutrition. Select all that apply. (Please note all feeding instructions should be handled by your pediatrician or health advisor)

Other

Does your baby receive any nighttime feedings?

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

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? (Note - As baby is learning this new skill, it's normal for them to shed tears as this is how they show frustration and protest. We will always ensure that all crying is controlled crying and that baby is always safe, fed and well.)

Other

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 HushPup?

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

Signature

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 HushPup.Baby LLC 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, HushPup.Baby LLC does not assume responsibility for errors, omissions, or contrary interpretations of the subject matter within the consultation. Reliance on any advice given by HushPup.Baby LLC 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, either verbally, written, or implied, remains the property of HushPup.Baby LLC 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 HushPup.Baby LLC is confidential. Any passing of any information to anyone is strictly forbidden and subject to international copyright laws.