Sleep Sweet Little One Intake Form

Your full name *
Your baby's name*
Baby's age and birthday*
What email address did you use for payment?*
What email address will you be using for the consultation?*
Was your baby born prematurely? (before 37 weeks)
Does your baby have any health issues I need to be aware of?
Does your baby have any siblings? Age?
What is your baby's current daytime sleep schedule (if any)?
How does your child fall asleep for naps and bedtime?*
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.

Yes, and I often have to reinsert it.Yes, but it's not a prop. My baby doesn't mind or cry for it when it falls out.No my baby does not use a pacifier.Other
Does your baby use any sleep props to fall asleep? or back to sleep during the night? Select all that apply.*

Nursing to sleepBottle to sleepRocking to sleepBouncing, swaying, or any other movementMy baby does not use any props to fall asleep at bedtime or during the nightOther
Which personality type best describes your baby. 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.Other
Have you tried any other methods or programs?*
What developmental milestones (if any) has your baby accomplished? Select all that apply*

None yetHolding head up when placed on bellyRolling onto sideRolling from belly to backRolling from back to bellySitting, but can't lay back downSitting, and knows how to lay back downCrawlingStanding, but can't sit back downStanding, and knows how to sit back downWalkingAll of the above milestonesOther
Which statement best describes how you feel about crying?*

I don't mind hearing cryingI don't mind hearing some cryingI cannot hear any crying at allOther
I want to mention that sleep training without any tears isn't possible. Your child will not have psychological damage or abandonment issues if you sleep train. Both you and your child will feel 100% supported through this process - I don't offer methods that would leave your child crying endlessly (Cry It Out style). Does this make sense and is this ok with you?*

Yes, absolutely.No, I just can't have any tears.
Do you have the support of a significant other while going through this process? Are they on the same page as you when it comes to wanting to sleep train?*

YES I have a significant other, YES they're on the same pageYES I have a significant other, NO they're not on the same pageNO I don't have a significant other/support, I'm doing this on my ownOther
Please provide in detail, any additional information that will help me understand what's going on with your baby'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.
Does your child attend Daycare?

Yes - Full TimeYes - Part TimeNoOther
How did you hear about Sleep Sweet Little One? *
Did a friend refer you? If yes, please tell me your friends name so that I can give that person credit
Do you want to start the consultation on a particular date? If not, leave today's date and I will begin working on a sleep plan as soon as possible. *Keep in mind that once the sleep plan is sent, your package begins from that date. (A 72 hour lead time is needed to create your custom sleep plan.)

MonthDayYear
Which package did you want to go with? *Other means - other option discussed on the Free 15 minute consultation call*

10 Day Support Package ($249)14 Day Support Package ($309)10 Day Support + 3 night bedtime support ($348)14 Day Support + 3 night bedtime support ($408)Other
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 Julie Nowlan-Pinette/Sleep Sweet Little One™ 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, Julie Nowlan-Pinette/Sleep Sweet Little One™ not assume responsibility for errors, omissions, or contrary interpretation of the subject matter within the consultation. Reliance on any advice given by Julie Nowlan-Pinette/Sleep Sweet Little One™ 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 once this form is submitted.

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 Julie Nowlan-Pinette/Sleep Sweet Little One™ either verbally, written or implied remains the property of Julie Nowlan-Pinette/Sleep Sweet Little One™ 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 Julie Nowlan-Pinette/Sleep Sweet Little One™ is confidential. Any passing of any information to anyone is strictly forbidden and subject to international copyright laws.

GENERAL:These terms of use shall be governed by, and interpreted in accordance with, the laws of the Province of New Brunswick, Canada. Julie Nowlan-Pinette/Sleep Sweet Little One™ reserves the right to amend or modify these terms of use at any time.
I have read and agree to the terms and conditions
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