Your full name
Your child's name
child's age (add adjusted age if baby was born premature)
Your preferred email for contact
Your location (state and time zone)
Anything medical that should be known about
What is your child's current daytime sleep schedule (if any)?
What does your child's bedtime routine look like? Skip if you don't have one.
What type of sleep outfit does your child sleep in?
What does your child's sleeping arrangement look like? Please be specific.
How many hours does your child sleep in a 24hr period. (Naps+ Night time sleep)?
Does your child use a pacifier to sleep.
Yes, and I often have to reinsert it.
Yes, but it's not a prop. My child doesn't 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 or back to sleep 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 any props to fall asleep at bedtime or during the night
Which personality type best describes your child. You may select more than one.
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.
Have you tried any other methods or programs?
What developmental milestones (if any) has your child accomplished? Select all that apply
Holding head up when placed on belly
Rolling onto side
Rolling from belly to back
Rolling from back to belly
Sitting, but can't lay back down
Sitting, and knows how to lay back down
Standing, but can't sit back down
Standing, and knows how to sit back down
All of the above milestones
Is your child with a caregiver (nanny, daycare, etc.) during the day? If so how many days a week? Are they willing to work with us and make changes?
Which statement best describes how you feel about crying?
I don't mind some crying I prefer a quicker method
I prefer less tears even if it means the method takes longer
Since tears are your child's form of communication, do you understand that I cannot promise no crying? I work with clients to minimize the tears.
Are you and any household members committed to following a plan?
What changes would you like to see in your child's sleep?
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, you can always add additional information by emailing me.
How did you hear about Erin Leetzow Sleep Consulting? Did a past client of mine refer you? If yes, please tell me their name.
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