Sleep Training Intake Please fill out this intake to help us learn more about your child and their sleep hurdles.. Your Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Baby's Name * Baby's Due Date MM DD YYYY Baby's Birth Date MM DD YYYY Baby's Sex Male Female Does Baby Have Any Health Issues Yes No If yes, please explain Tell us about your child's sleeping environment My child sleeps in a crib My child sleeps in a toddler bed My child sleeps in our bed Something else If you responded "something else", please clarify below How is Baby Fed? check all that apply Breastfed Bottle Fed Breastmilk Bottle Fed Formula Eating Some Solid Food Eating Only Solid Food Has your pediatrician given you the green light to drop all nighttime feeds? Yes No I'm not sure Choose all that apply to your child's sleeping environment My child's room has blackout curtains on the windows and is very dark while sleeping for naps and nighttime sleep My child's room has a white noise machine that plays consistent white noise (not music or other intermittent sounds) My child sleeps alone in their room (no other siblings or caregivers) My child sleeps with a sleep sack on My child's room is equipped with a smart monitor that can be accessed remotely My child's room has a consistent temperature between 68-72 degrees My child's crib or bed is free of accessories like stuffed animals, toys, etc. My child's room is located in a part of the house that is quiet and without distractions My child uses a pacifier (and can put it in on their own) My child uses a pacifier (and cannot put it in on their own) Does your child fall asleep independently for naps and bedtime? (they are awake when you put them in their bed and when you leave their room) Yes, just naps Yes, just bedtime Yes, both naps and bedtime No How often does your child wake up at night? 1-3 times 3-5 times Not at all More than 5 times What happens when they wake up at night? (do you go in? what do you do to get them back to sleep? do they CIO? etc) If they used to be a good sleeper, when did things change and do you know what caused the change? What time does your child go to sleep each night? Please explain your child's napping routine/schedule * Timing, length of nap, routine, how many per day, location, etc. What time does your child wake up each morning? Have you tried any sleep training methods in the past? Yes No If yes, which ones and did they work? What did you like and dislike about them? How would you describe your child's temperament? Check all that apply Easy going and can handle frustration very well Easy going but isn't always able to handle frustration well Sensitive to any changes and becomes easily frustrated Sensitive and clingy to parents Okay with independent time Okay while with people other than parents Cries often Only cries when something is wrong Cries for no reason Rarely Cries Has a hard time sleeping in new environments Will not fall asleep in a car seat or stroller Can fall asleep in a car seat or stroller How comfortable are you and your partner (if applicable) with your child crying if they aren't in distress or needing anything from you? There's no right or wrong answer! Very comfortable Somewhat comfortable Uncomfortable but willing to work through that feeling to allow it to happen Very uncomfortable and won't allow it Is your child pulling themselves up to standing? Yes No Only inconsistently Is your child sitting up on their own? Yes No Only inconsistently Is your child rolling from back to front, and front to back on their own? Yes No Only inconsistently What is the brand and model of your video monitor? WiFi network name and password Has your child been sick recently? Yes No They're currently sick If yes, please explain Do you have any pets in the home? * Cats Dogs Is there a separate space for me to sleep while doing your Overnight Care and/or Sleep Training? Yes, in our guest room Yes, on a couch Yes, on an air matress Yes, but TBD Any special info I should know about finding your house and/or where to park? In your own words, please tell us why you're seeking our support with sleep training and anything else that you think is important for us to know. What are your sleep goals for your child? If you had a magic wand, what would your child's sleep be like? Thank you! We will be in touch soon to schedule your follow-up intake call to go over these answers with you.
