Parent Questionnaire Intake Form
Applicant & Contact Information
Email
*
example@example.com
First Name
*
Last Name
*
Email you wish to use for consultation
*
example@example.com
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Complete Home Address
*
Child Information & Sleep Context
Your child's full name
Your child's age
Do you have a spouse? If so, will they be involved in the sleep training process? Please share their name
*
What is your child's current daytime sleep schedule (if any)?
What does your child's bedtime routine look like?
What does your child wear at bedtime? Examples: swaddle, sleep sack, footed sleeper/pajamas
What does your child's sleeping arrangement look like? Please be specific
*
Please describe, in as much detail as you can, the environment in which your child sleeps. Examples: in their own room, in a room shared with a sibling, in a crib/swing/bassinet, blackout shade on the window, mobile over the crib, sound machine, etc.
How many hours does your child sleep in a 24-hour period?
Care Arrangements, Sleep Props & Feeding
What are your child care arrangements?
Home with a parent
Home with a nanny
Daycare
Other
Other (child care arrangements)
Does your child use a pacifier to sleep?
Yes, and I often have to reinsert it
Yes, but it's not a sleep prop - my child doesn't mind if it falls out
No, my child doesn't use a pacifier
Does your child use any sleep props to fall asleep?
*
Nursing to sleep
Bottle to sleep
Rocking to sleep
Bouncing, swaying or any other movement
My child doesn't use any props to fall asleep at bedtime or during the night
Other
Other (sleep props)
Is your child breastfed or bottle fed? If your child is weaned from the breast or bottle, please just write N/A.
Is your child being fed in the middle of the night? If so, please explain how often/how much.
If your child is over the age of two, how much screen time is allowed?
Child Development, Temperament & Sleep Concerns
Which describes your child's personality?
*
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 to get your child to sleep better?
*
Which developmental milestones has your child accomplished?
*
None yet
Holding head up when placed on belly
Rolling onto side
Rolling from belly to back
Rolling from back to belly
Sitting with support
Sitting independently
Crawling
Pulling to stand
Walking
Other
Which statement best describes how you feel about crying?
*
I don't mind hearing crying
I don't mind hearing some crying
I cannot stand to hear any crying
Please provide any additional information about your child's sleep troubles. Do you want to start the consultation on a particular date? If not, enter today's *date and I will begin working on a sleep plan right away. Keep in mind, once thesleep plan is sent, your consultation begins on that date.
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