Lullaby & Me Intake Form

Your full name

Your baby's name

Baby's age

Baby's weight

Email Address

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What is your baby's current daytime sleep schedule (if any)?

Was your baby a preemie? If so, what is their adjusted age?

What does your baby's bedtime routine look like? Skip if you don't have one.

What type of sleep outfit does your baby sleep in?

What does your baby's sleeping arrangement look like? Please be specific.

How many hours does your baby sleep in a 24hr period. (Naps+ Night time sleep)?

Does your baby use a pacifier to sleep.

Other

Does your baby have any overnight feedings?

If you answered "Yes" for the above question. How many overnight feedings?

Is your baby or toddler formula fed, breastfed or both?

How many ounces does your baby get in a 24 hour period?

An estimate is fine

Does your baby eat solids? If so how many times a day?

Does your baby use any sleep props to fall asleep? or back to sleep during the night? Select all that apply.

Which personality type best describes your baby. You may select more than one.

Other

Have you tried any other methods or programs?

What developmental milestones (if any) has your baby accomplished? Select all that apply

Does your child have any of the following?

Which statement best describes how you feel about crying?

Other

Please provide in detail, any additional information that will help me understand what's going on with your baby's sleep troubles. What is your end goal? 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.

When are you hoping to begin sleep training?

Are you prepared to invest in a personalized sleep program?

How did you hear about Lullaby & Me?

Did a friend refer you? If yes, please tell me your friends name so that I can give that person credit

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 Irene Makriplis, Elizabeth McLaughlin, Lullaby & Me LLC or any of its employees/consultants be liable to you for any claims, losses, injury or damages as a result of reliance on the information provided. All though all attempts have been made to verify the information provided is accurate, Irene Makriplis does not assume responsibility for errors, omissions, or contrary interpretation of the subject matter within the consultation. Reliance on any advice given by Irene Makriplis or Elizabeth McLaughlin is solely at your own risk.

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 Irene Makriplis, Elizabeth McLaughlin or other Lullaby & Me Sleep Consultants either verbally, written or implied remains the property of Lullaby & Me LLC at all times. Written permission is required to reproduce, record, publish or advise verbally any details of the provided sleep plan, E-guides, 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. Any information supplied by Irene Makriplis/Lullaby & Me LLC is confidential. Any passing of any information to anyone is strictly forbidden and subject to international copyright laws.

REFUND POLICY:

Due to the personalized nature of our sleep consulting services, all payments are final once your individualized sleep plan has been prepared and sent to you.

By submitting payment and completing your intake information, you authorize Lullaby & Me Sleep Consulting to begin reviewing your child’s sleep history and preparing your customized sleep plan.

Once the sleep plan has been delivered, no refunds, cancellations, credits, or partial refunds will be issued, including in situations where:

You choose not to implement the sleep plan;
You discontinue the program before the consulting period has ended;
Your child’s sleep does not improve as quickly as expected;
You are unable to complete the recommended strategies; or
You decide that sleep consulting is no longer a good fit for your family.
Sleep outcomes vary based on the child, family circumstances, consistency of implementation, developmental factors, health considerations, and other circumstances outside the control of Lullaby & Me Sleep Consulting. Therefore, specific results cannot be guaranteed.

If you experience an issue accessing your sleep plan or purchased consulting services, please contact Lullaby & Me Sleep Consulting so we can assist you.

By purchasing a sleep consulting package, you acknowledge and agree to this Refund Policy.

Please check the box and sign below

Signature

You will receive a response within 48 hours by text.

Thank You!

Irene Makriplis

Certified Pediatric Sleep Consultant

Lullaby & Me