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First Name *
Partner's Name (if applicable) *
Last Name *
Phone Number *
Email Address *
Child's Name *
Child's Age and Birthdate *
Was Your Child Born at Term/Premature/Late? Please Give Details. *
What Was Your Child's Birth weight? *
What is Your Child's Current Weight? *
Do You Have Other Children? If Yes, Please List Their Ages. *
Where Does Your Child Sleep? (cot, car naps, family bed, floor bed etc.) *
Does your child use a comforter or dummy? Please give details. *
In which Room Does Your Child Usually Sleep For Naps? *
In Which Room Does Your Child Usually Sleep For Night Sleep? *
What Does Your Child Sleep In? (sleeping bag/PJ's/blankets) *
Do you use a video monitor? *
Please Describe Your Child's Sleep Environment (darkness/white noise/fan/air conditioning/night light etc.) *
Does Your Child Use a Dummy and/or Cuddly? If Yes, Give Details (only at night/in the car, very attached to cuddly/not fussed) *
If Breast Fed, Please Indicate Approximate Feed Times, Day and Night. *
If Formula Fed, Please Specify Volume and Approximate Times of Feeds, Day and Night. *
Please Indicate Approximate Times of Meals and Give Examples of Types and Amounts of Food Usually Eaten. *
Feel Have Child
In your Opinion, is Your Child Reaching Age Appropriate Milestones? *
Please Describe Your Child's Temperament (easy going/quite fussy/generally happy etc.) *
Does Your Child Have Any Medical Conditions or Current Health Concerns? If Yes, Have You Consulted With a Health Professional? *
How Do You Settle Your Child to Sleep? (rocking/patting/feeding/other) and For How Long? *
Please Describe a Typical Day From Wakeup in the Morning to Bedtime at Night (include nap times/lengths, activities, feeds and any other routine events in your child's day). *
Please Describe a Typical Night from Bedtime at Night to Wakeup in the Morning. *
Please Describe Any Regular Commitments That Require You to be Out of the House at Certain Times (school run, shopping, work). *
Do You or Have You Suffered Anxiety, Depression or Other Mental Illness? (leave blank if you prefer not to answer).
Describe Your Parenting Style. Do You Prefer Routine or a More Relaxed Style of Parenting? *
What Would You Like to Work on Regarding Your Child's Sleep? (be as specific as you can) *
Have You Ever Tried Any Kind of Sleep Training? If Yes, Please Give Details. *
Please Add Any Other Information You Feel is Important or That You'd Like to Discuss During Your Consultation Call.
