Intake Assessment Form
Fais Dodo Sleep Solutions
Parent(s) Name(s)
First Name
Last Name
First Name
Last Name
Which email would you prefer to use for the consultation?
Which phone number would you prefer to use for the consultation? (If applicable)
-
Area Code
Phone Number
Child's Name
First Name
Last Name
Child's Date of Birth
Child's Adjusted Age
If under 2 years old and applicable
Child's Sibling(s) and Age(s)
If applicable
How many hours does your child sleep in a 24hr period (naps + nighttime sleep)?
What is your child's current daytime sleep schedule? Morning wake up time, start times and end times of naps where applicable, and bedtime.
Example: Wake-up 7am, 1st nap 11:00 – 12:00, 2nd nap 3:00 – 4:00, Bedtime 8pm
Does your child attend dayhome or daycare?
No
Yes, dayhome
Yes, daycare
What does your child's bedtime routine look like?
Example: Breast/Bottle, bath, PJ's and sleep sack, book, etc.
What does your child wear to sleep?
Example: Cotton sleeper, fleece sleep sack, short sleeve PJ's, etc.
Do you use white noise?
Yes
No
Do you use a night light?
Yes
No
What does your child's sleeping arrangement look like? Please be specific.
Examples: Baby/child sleeps in own crib/bed and room, no siblings in the room, or, baby sleeps in a bassinet in parent's room on mom's side of the bed.
Does your child experience nighttime wake-ups?
Rarely
Sometimes
Often
Multiple times a night, every night
Does your child use a pacifier to sleep?
Yes, and I often have to reinsert it.
My child does not mind or cry for it when it falls out
No, my child does not use a pacifier
Does your child use any sleep props to fall asleep at night? Select all the apply.
Nursing to sleep
Bottle to sleep
Rocking to sleep
Bouncing, swaying or any other movement
My child does not use props to fall asleep at bedtime
Does your child use any sleep props to fall back asleep during the night? Select all that apply.
Nursing to sleep
Bottle to sleep
Rocking to sleep
Bouncing, swaying or any other movement
My child does not use props to fall back asleep during the night
Does your child use any sleep props to fall asleep at nap time(s)?
Nursing to sleep
Bottle to sleep
Rocking to sleep
Bouncing, swaying or any other movement
My child does not use props to fall asleep at nap time(s)
Which personality type best describes your child? You may select more than one.
Quiet, mellow, laid back, does not mind change
Cranky, fussy, rarely in a happy mood
Clingy, anxious, often experiences separation anxiety
Strong willed, stubborn, often resists change
Happy, playful, usually in great spirits
Which developmental milestones has your child accomplished? Select all that apply.
None yet
Holding head up when placed on tummy
Rolling onto side
Rolling from tummy to back
Rolling from back to tummy
Sitting, but can't lay back down
Sitting, and knows how to lay back down
Crawling
Standing, but can't sit back down
Standing, and knows how to sit back down
Walking
All of the above milestones
Which statement best describes how you feel about crying?
I don't mind hearing crying
I don't mind hearing some crying
I cannot hear any crying at all
Please provide in detail, any additional information that will help me understand what's going on with your child'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.
Have you tried any sleep methods or programs?
How did you hear about Fais Dodo Sleep Solutions?
Did a friend refer you? If yes, please tell me your friend's name so that I can give that person credit.
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