Shore to Sleep Intake Form

Your Name*

First NameLast Name

Your Email Address*

example@example.com

Why did you choose Shore to Sleep?

Phone Number*

Please enter a valid phone number.

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Child's Name*

Child's Age and Date of Birth*

Was your child born full-term or premature? If premature, what was the gestational age at birth?*

What are the names of the people who will be involved in sleep training?*

Please include your occupations and working hours including any weekend work that you feel would be beneficial for me to know. This is helpful to understand the times at which you are all home and how I can better assist you with making recommendations. *

Who lives in the house with you? Provide ages of siblings to better help me understand the dynamic of the house!*

What goals do you want to achieve while working with me? List as many as you'd like.*

What is your ideal bedtime?*

What time does your child typically wake for the day?*

What time(s) and how long are your child's nap(s)?*

What time does your child typically go to bed?*

Where does your child sleep? Address any of the following areas: in their own room, room sharing, bed sharing, crib for naps but bassinet in our room for night sleep etc*

Is your little one's sleep space completely dark for all sleep? Including daytime*

YesNoCould be darker

Are you using a sound machine for sleep?*

YesNo

Do you have a mobile above babies crib?*

YesNoN/A

Are you using a nightlight in your child's room?*

YesNo

I place my child down:*

AwakeDrowsyAsleep

Does your child use any sleep props to go to sleep?*

If you answered "other" to above, please describe below

Does your child use a pacifier to sleep?*

Yes, but not as a sleep prop. It doesn't matter if it falls out.Yes, and I constantly have to put it back in.No, my child doesn't use a pacifier.

Does your child wake at night?*

YesNo

How many times a night is your child waking?*

1 or less2-33-45+

How do you respond for night wakings? Example: I go in right away and pick him/her up and rock back to sleep.*

How many night feedings does your child currently have?*

How many night feedings would you like to have? Please check with your pediatrician on what is developmentally appropriate for your child.*

Do you have a bedtime routine?*

YesNo

How long is your bedtime routine?*

What is your bedtime routine?*

Any recent developmental milestones within the last 2 weeks? For example: rolling, crawling, walking, talking*

YesNo

What is the new milestone?

On a scale of 1-10, 10 being mastered and 1 being just started. At what level do you feel they have mastered the above milestone? If there is more than one, rate the one they are working on the most.

Have you tried any other methods and/or programs to get your child to sleep better? If so, explain below*

What is your cry tolerance?*

What is your level of anxiety (10 being the highest) in regards to teaching your child independent sleep?*

If you are comfortable sharing with me, are you currently struggling with any of the below. I want to ensure I am aware of any*

I have been diagnosed with a perinatal mental health disorder (anxiety, depression, OCD etc.)I think I may be struggling with one of the above, but have not been diagnosedI am not sureI am feeling goodN/A I prefer not to share

If you would like to share more information regarding your mental health, please do so below. This is not required.

What is your childcare arrangement?*

Home with a parentHome with a nannyDaycare/SchoolOther (describe below)

If you answered "other" above please describe child care arrangements below.

If your child is not home during the day, what time do you typically drop them off and what time do you pick them up for the day?

Do you have any important events coming up in the timeframe that we will be working together? This is important for times/days that you will be away from your home for nap and bedtime.*

Please provide any additional information you would like me to know about your child, your situation, and what is currently going on. You can skip over if you feel all information about your child was addressed above.

TERMS AND CONDITIONS

BY SIGNING BELOW YOU AGREE TO THE FOLLOWING TERMS AND CONDITIONS: MEDICAL DISCLAIMER: The information/advice provided during this consultation is not medical advice. You are not establishing a medical professional/patient relationship. The advice is for informational purposes only and is intended for use with healthy children with common sleep issues that are unrelated to medical conditions. The information provided is not intended nor is implied to be a substitute for professional medical advice. Always seek the advice of your physician with any questions you may have regarding a medical condition or the health and welfare of your baby.

PEDIATRICIAN APPROVAL: You agree to consult with and get approval from your pediatrician before following the advice or using the techniques offered during this consultation.

LEGAL NOTICE: In no event will Shore to Sleep or Catherine Rehm be liable to you for any claims, losses, injury or damages as a result of reliance on the information provided. Although all attempts have been made to verify the information provided is accurate, Shore to Sleep or Catherine Rehm does not assume responsibility for errors, omissions, or contrary interpretation of the subject matter within the consultation. Reliance on any advice given by Shore to Sleep is solely at your own risk.

REFUND POLICY: Due to the amount of time, effort, and commitment provided within a consultation, refunds are not possible. If you are unhappy in any way and not receiving value from your program, please communicate this with me ASAP so that we can resolve the issue.

COPYRIGHT NOTICE: The information provided within the consultation may not be reproduced, republished, or transmitted in any form or by any means mechanical or electronic, including photocopying and recording, or by any information storage and retrieval system, without permission.All information supplied by Shore to Sleep either verbally, written or implied remains the property of Shore to Sleep at all times. Written permission is required to reproduce, record, publish or advise verbally any details of the provided sleep plan, charts, notes, advice offered or consultation transcript or summary in any format whatsoever. This includes but is not limited to any details published on any blogs, forums, or similar boards.

CONFIDENTIALITY NOTICE: Any information supplied by Shore to Sleep is confidential. Any passing of any information to anyone is strictly forbidden and subject to international copyright laws. All information shared with Shore to Sleep will remain confidential.

Signature

Goals

Sleep Schedule

Sleep Environment

Sleep Details

Night Wakings & Feedings

Bedtime Routine

Developmental Milestones

Sleep Methods

Childcare

Other Important Information