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FREE Sleep Resources + Q&A Sessions
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Toggle Navigation
Welcome
About
Blog
Resources
Blog
FAQs
The Science of Sleep
Facebook Live Q & A
Get Sleep!
Newborn Nap Guide
Toddler Sleep Guide
Baby (4-12 Months) Sleep Consultation
Toddler (1-5 Years) Sleep Consultation
Mini-Consultations
Contact Us
Mini-Consultation Intake Form
admin
2021-07-10T16:40:28+00:00
Mini-Consultation
Intake Form
Please fill out the form below with as much detail as possible. The information you provide is kept confidential and is only used to assist with your consultation, sleep plan and support time.
Child's Name
First
Last
Child's Current Age
Child's Date of Birth DD/MM/YYYY
Medical Issues or Concerns:
Please list any current or previous medical issues including reflux, food or environmental allergies, etc.
Tell me about your child; personality, likes/dislikes, favourite activities, etc.
Tell me about the sleep challenges your child is facing.
Describe to me how these challenges are impacting your life.
How does it feel to be struggling with these sleep issues? What frustrates you the most about it?
Parent's Information
Parent 1 Name
First
Last
Parent 1 Occupation
Parent 1 Age
Parent 2 Name
First
Last
Parent 2 Occupation
Parent 2 Age
Contact Information
Please list the best option to reach you at.
Phone Number
Cell Phone (Optional)
Email
Child's Doctor
How Did You Hear About Baby Sleep 101?
Facebook
Referral
Internet Search
Attended Presentation or Workshop
Other
Why did you choose Baby Sleep 101?
Have you ever worked with another sleep consultant?
Child's History
Was your child born early? If so, when?
When was your child's last visit to the doctor?
Was your child considered colicky as a newborn?
Yes
No
Were your child's sleep issues discussed?
Yes
No
Child's Daily Routine
What time does your child wake up for the day?
Please list what time your child naps at each day. Be sure to include starting and ending times.
Please list the days and times of any classes, activities or events that your child attends, including daycare or school.
What time is your child's bedtime?
How long does it take your child to fall asleep at bedtime?
0-15 minutes
15-30 minutes
30-60 minutes
1-2 hours
Can your child fall asleep without your help or presence?
Yes
No
Sometimes
What does your child use to help them fall asleep? Please check all that apply.
Swaddle
Pacifier
Lovey or stuffed animal
Night light
White noise/fan/static
Music
Special or favourite blanket
What sleep associations does your child have, if any?
Nursing/sucking to sleep
Rocking to sleep
Holding to sleep
Co-sleeping or needing a parent to lie down with them
Other
Please describe your child's wind down routine before both naps and bedtime.
When you put your child to bed, please rate their level of wakefulness, with 1 being wide awake and 5 being in a very deep sleep.
1-wide awake
2-very relaxed, but eyes still wide open
3-eyelids drooping, closing off and on
4-eyes are closed, but still awake
5-very deep sleep
Does your child wake for feedings? If so, what time do they occur?
How many times does your child wake each night? Include night feedings if applicable.
o-1
1-2
2-3
3-4
4-5
5-6
6+
How do you handle the night wakings? Please be as specific as possible.
Child's Sleeping Environment
Where does your child sleep for the majority of their naps and nights?
Please rate the level of darkness in your child's room; 1 being bright and sunny, and 5 being pitch black.
1
2
3
4
5
Where is your child's room in relation to the rest of the house?
For example; upstairs at the end of the hallway, borders the washroom, parents room or siblings room, main floor next to living room, etc.
Parent History
Please descibe you and your partner's (if applicable) personalities.
How many hours a night do you estimate you and your partner (if applicable) are sleeping?
Please list any books you have read on sleep and your opinion of them.
Parenting Philosophy
Please describe your parenting philosophy.
Please list any sleep philosophies that you are either comfortable or uncomfortbale with. Please explain why.
How do you feel when your child cries in the daytime? How about at night? How do you feel about crying in general?
Goals and Expectations
What are your goals for your child's sleep routine? Please list in order of importance if there is more than one.
Are all caregivers committed to your child getting restful and restorative sleep?
Are there any roadblocks that may inhibit progress; either personally (one caregiver is impatient or easily frustrated) or schedule wise (daycare, work schedules, appointments, etc.)?
Is there anything else you feel it's important for me to know or that you would like to share?
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