Scarlet Robin Sleep Questionnaire

Thank you for your interest in a Scarlet Robin Sleep Supoprt Package. We look forward to supporting you and your family.

Please could I ask that you complete and submit this form.

Once complete I will then forward an invoice relating to your choosen sleep package. We can then agree a time and date to work through your plan.

Should you have any questions please do not hesitate to ask.

Really looking forward to getting to know you.

Jessica Halestrap

Scarlet Robin Sleep Consultant
Please fill out the form below with your information and preferences.
Your Full Name*

First NameLast Name
Your Phone Number*

Area CodePhone Number
Your Email Address*
example@example.com
Your child's name **
Your child's of Birth

DayMonthYear
Date
Select Your Country*
Address (The Gold Nest package - London only)

Street Address

Street Address Line 2

TownCity

Postal / Zip Code
What Sleep Package are you interested in?

The Nest ConsultationThe Newborn Nest Consultation (0-12 weeks)The Robin Reset (4-12 months)The Scarlet Signature packageThe Gold Nest PackageOther, unsure please contact me to discuss
Has your child got any allergies or medical diagnosis?
Does your child currently avail of a nap schedule? If so, describe it here....
What does your child's bedtime routine look like? Include who puts them to bed, and how they fall asleep
What does your child's sleeping environment look like?
Does your child use a dummy?

Yes and I often have to reinsert itYes, but if it falls out they do not need it reinsertedNoOther
If other please describe
Which developmental milestones (if any) has your child accomplished? Select all that apply. (This will give you an idea as to whether you need to support them with laying down or whether swaddle needs removed)

RollingSitting but can't lay back downSitting and knows how to lay back downStanding but can't sit back downStanding but can sit back down
Does your child experience any of the following symptoms. Please tick all that apply.

Flushed faceExcess gasBloating of the abdomenDrawing their legs up to their stomachRegurgitating feedsRe-occurring hiccupsFrequent coughingNot gaining weightForceful vomitingSpitting up green / yellow fluidSpitting up what resembles coffee groundsBlood in stoolMucus in stoolGreen / frothy stoolsInflamed peri-anal skin (burnt bum syndrome)ConstipationItchy eyesWheezingSwelling of the faceRedness around the anus or genitals
Which of these activities apply yo your child? If your child is under 18 months skip this question (This is to help determine their sensory preferences)

Messy PlayJumping on trampolinesTwirling aroundSplashing in the bathMoving their headMy child prefers a calm atmosphereMy child is fussy about the feel of different materials
How does your child respond when you leave the room? If your child is under 6 months skip this question).
TERMS AND CONDITIONS

BY SIGNING BELOW, YOU AGREE TO THE FOLLOWING TERMS AND CONDITIONS:

MEDICAL DISCLAIMER: The recommendations provided during this consultation is not a substitute for medical advice. The advice is intended for use with children without diagnosed medical conditions or undiagnosed symptoms. Always seek advice from a medical professional regarding any concerns about your child’s health. It is recommended to obtain your doctors permission before using any of the behavioural strategies provided.

LEGAL NOTICE: In no event will Jessica Halestrap, Scarlet Robin, be liable to you for any claims, losses, injury or damages as a result of reliance on the information provided. Jessica Halestrap and Scarlet Robin does not accept responsibility for errors, omissions, or contrary interpretation. Using this plan is solely at your own risk.

REFUND POLICY: Payment is required to secure the booking. Refunds are not possible after payment has been made.

COPYRIGHT NOTICE: The information provided is subject to Copyright Law. It must not be shared reproduced without permission from the author.
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