Client Intake Form
Child's Name and Age
Was your child born before 40 weeks?
What is your child's current daytime schedule, if any?
Example: Wake 6:30am Nap 9:00-10:00 Nap 12:30-1:30 Nap 4:00-5:00 Bed 8pm
What does your child's bedtime routine look like?
How does your child fall asleep for naps and at night?
On their own
Where does your child currently sleep?
What issues are you experiencing / how can I help?
Have you tried sleep training before? If so, which method or program did you use? Put N/A if none.
Anything else I should know? Medical issues, parenting style, temperament?
Due to the work that goes into creating a custom sleep plan for your child, I do not issue refunds except under extenuating circumstances. Signing this form validates that you will follow this plan and understand that any additional support from me outside of your selected plan will incur the fee listed on the Insomnia Mama website.
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm