Massachusetts Sleep Consultants Intake Form

Pediatric Sleep Consulting Intake Form

Please provide information about your child’s sleep habits and your family’s contact details to help us tailor our services.
Parent/Guardian Full Name*

First NameLast Name
Child's Full Name*

First NameLast Name
Child's Age (in months/years)*
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Preferred Contact Method*

EmailPhone CallText MessageOther
Who primarily helps with your child’s care during sleep times?*

MotherFatherGrandparent(s)Nanny/BabysitterOther
Describe your child’s typical sleep schedule (bedtime, wake time, nap times)*
What sleep aids does your child use? (e.g., pacifier, white noise, swaddle, special blanket)*

PacifierWhite Noise MachineSwaddle/Sleep SackSpecial Blanket or ToyNoneBeing Held to SleepFeeding to SleepOther
How would you describe your child’s current sleep patterns? (e.g., how many times do they wake at night, how long to fall asleep)*
Describe your child’s sleep environment (room, lighting, temperature, crib/bed, etc.)*
How do you feel about your child crying at night?*

I am comfortable allowing some cryingI prefer to respond immediatelyIt depends on the situationOther
Additional Comments
Please provide any additional comments or information about your child's sleep.
Should be Empty:

Pediatric Sleep Consulting Intake Form