Intake Form FacebookThis field is for validation purposes and should be left unchanged.Parent's Names(Required) First Email(Required) Requested Sleep Services(Required)Select OneExpecting ParentsNewborn Private CoachingInfant Sleep CoachingToddler & School Age ChildrenPin Point CoachingDue Date MM slash DD slash YYYY What is your child's name?Age & Date of BirthNames & ages of any siblingsIs your child on any medication?Any health issues or concerns?What books have your read to prepare for your new baby?Where will baby sleep?Do you have any specific questions you’d like to cover during our meeting?Have you selected your pediatrician?Doctor/Practice Name?Do you plan to breast or bottle feed?Baby's Current WeightWas your child premature?Did he/she have colic or reflux?Tell me about your baby. Likes, dislikes, temperament etc.Have you spoken to your doctor about your baby’s sleep difficulties?Is your baby currently working on any of the following? Rolling Sitting Crawling Self-Feeding Standing Walking Talking Does your baby take a pacifier? Yes No What time does your baby wake to start his/her day?What happens at this time? They are given a bottle Breastfed Start with solids What signals do you notice your baby gives when he/she is tired?How do you dress your baby for sleep?Is your baby under the care of another caregiver, home with you, daycare, grandparent?How many days a week? Drop off/pick up time?How many naps does your baby take?How do you get your baby to sleep for naps? Duration?What time do you start getting your baby ready for bed?What routine do you do with your baby when getting them ready for bed? (For example: bath, brush teeth, sing songs, read stories, play a game, etc.)Is your baby swaddled or wearing a sleep sack? What type?What time does your baby actually fall asleep at bedtime?How does your baby fall asleep at this time?What happens during the night? (Best AND worst case scenarios.)Have you read any books about baby sleep, and have you tried any suggestions from these books in the past?Was there a time when your baby slept well and then things changed?Where is your baby sleeping at night? Your room, their room? Crib/co-sleeping?Where would you ideally like them to sleep?Where does your baby nap?Is your baby breast or bottle fed?What is baby’s feeding schedule? How much or for how long are they eating?If possible are you ready to drop night feedings?Does your baby have any allergies or sensitivities?What is your top sleep goal?Do you have any specific concerns you’d like to share with me?Pediatrician Name & Phone NumberMay I contact your pediatrician and let them know we worked together? Yes No Names of all caregiversTell me about your child’s fun personality, the likes and dislikes:Does your kiddo have any food allergies or sensitivities?How would you rate their eating habits? Picky eater Healthy appetite Only eats the same 5 things How much juice or milk does your child consume in a day?What would an average day of food consumption look like?Breakfast, snacks, lunch, dinner, treatsWhat time is dinner?Does your child have any snacks right before bed? If so, what?Are there any developmental delays or concerns for your child?Sleep QuestionsDoes your child snore or is he/she a heavy mouth breather?What time does he/she start the day?What happens currently?Where does your child sleep, and do they share a room with anyone?Crib, bed co-sleep with parent or sibling?On a scale of one to ten, with ten being extremely dark, how dark is your child’s room at bedtime and through the night?Please enter a number from 1 to 10.Total screen time?Does your kiddo ever take a daytime nap? If so, when and where?What time do you start the bedtime routine?What are the steps of the routine?Do any of the following apply to your child? Ask for sitting or laying with them Overnight wakings to come to your bed Nightmares or night terrors Stalling at bedtime Anxiety Parent preference Early morning wakings What time is he/she actually asleep?Was there a time when your child did sleep well, and things changed?Parent HistoryWhat are the most frustrating or difficult issues for you around your child’s current sleep habits?What would be your number 1 sleep goal?Has your family experienced any major life changes or traumas that could be affecting your child?Is there a family history of depression or anxiety disorders?Are there any schedule challenges with getting your child to bed on time?Are there any concerns or worries about getting your child to sleep well?Is everyone in the household committed to seeing your child sleep well and on his/her own?Is there anything else you’d like to share with me that you think I should know before we meet?
