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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 So, Please List Their Ages. *
Where Does Your Child Sleep? (bassinet, cot, family bed etc.) *
Do You Swaddle Your Child? If Yes, How? (arms up/down, type of swaddle etc.) *
In which Room Does Your Child Usually Sleep For Naps? *
Milk (if Your
In Which Room Does Your Child Usually Sleep For Night Sleep? *
What Does Your Child Sleep In? (sleeping bag/PJ's/blankets) *
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. *
If Your Child Has Solids, Please Indicate Approximate Times of Meals and Give Examples of Types and Amounts of Food Usually Eaten. *
Please Describe Your Child's Development. In your Opinion, is he/she Reaching Age Appropriate Milestones? (your child health record book should have descriptions of these if you're not sure) *
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. *
