Welcome!

I am so excited to have you on board as a client. First step, download your sleep tracker packet below. This will help you and I keep track of your child’s sleep daily.

Download Your Sleep Tracker Packet

Next, you’ll fill out my intake form here. Be as thorough as possible. Also, fill it out with all honesty, there is absolutely no judgement from me! Make sure to hit SUBMIT at the end so that it is sent to me.

Intake Form

Child's Name

Child's Estimated Due Date

Child's Current Age + Birthday

Parents' First and Last Names

First Name

Last Name

Email Address

Phone

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Parental Leave (Maternity/Paternity) End Date

Child’s History

1. Have you discussed your child’s sleep issues with your pediatrician? If so, please explain what concerns were brought forward and what the doctor advised.

2. Does your child have any medical issues we should be aware of (reflux, allergies, etc.)?

3. Was your child born early? If so, when?

4. Were there any complications during delivery? If so, what were they?

5. Was your child ever considered colicky? If so, how long did it last?

6. Does your child snore or mouth breathe?

Child’s Daily Routine

7. What time does your child wake for the day?

8. How many times per day does he/she nap? Please list the time and duration of each of the naps.

9. Please describe your wind down routine (if you have one) before naps.

10. Please describe your child’s bedtime routine, or any variances from the nap wind down routine.

11. Do you know what signs your child gives to show they are tired and ready to sleep? If so, what are they?

12. What time is your child’s bedtime?

13. How long do they normally take to fall asleep?

14. Can they fall asleep without your help or presence?

15. Does your child use a pacifier? A swaddle?

16. Does he/she experience night waking’s? If so, how many per night? Duration? Describe them here:

17. How do you handle them/what is your response? Please be specific as possible.

18. Does your child wake for feedings? If yes, how many times? What time do these waking’s typically occur?

19. Tell me about your child’s feedings- breast milk or formula, any solid food?

Temperament and Personality

20. How would you describe your child’s temperament/mood/attitude during the day?

21. How would you describe your child’s personality?

Child’s Sleeping Environment

22. Where does your child sleep? Please list all of the environments that your child typically sleeps in below; (i.e. crib, family bed, stroller, car, etc.)

23. Please rate the level of darkness in his/her room- 1 being bright and sunny, and 5 being absolutely pitch dark;

24. Does your child have a lovey, blanket or stuffed animal that they use to fall asleep? If yes, how is it incorporated into the bedtime routine?

25. When you put your child to sleep please describe their state of wakefulness from 1-5, 1- being wide awake and alert, and 5 being in a very deep sleep;

Parent History and Family Philosophy

26. Have you read any books on sleep; if yes which ones? What did you think of them?

27. Are there any sleep philosophies you agree or disagree with? If yes, please explain why;

28. How do you feel when your child cries in the day? How about at night? How do you feel about crying, in general?

29. Is everyone committed to your child getting restful and restorative sleep?

30. What roadblocks or hindrances do you see that may inhibit progress-either personality wise (ie-one parent is impatient, or easily frustrated, etc.) or schedule wise (day care, work schedules, appointments, etc.)?

Parents' Sleep History

31. How many hours a night do you estimate you and your partner (if applicable) are sleeping?

Goals and Expectations

32. How is your child's sleep issue affecting you?

33. How long do you expect sleep training/routine setting to take?

34. How long would you like sleep training to take before you see some result, even small ones?

35. Please tell me what your goals are for your child in terms of their sleep/routine. If you have more than one, please list in order of importance.

36. Please add anything that you would like to share or feel I should know:

Don’t forget to hit that SUBMIT button above so I receive the intake. Lastly, print this contract out and send it back to me so that we can seal the deal and get sleep restored in your household!

Client Contract