Pediatric Sleep Consulting Intake Form

Client Information

Parents Full Names: *

Email: *

Phone Number: *

Child's Name: *

Child's Date of Birth: *

Current Weight: *

Is your child breastfed, formula-fed, or combination? *

Breastfed

Formula-fed

Combination

Is your child eating solids? If yes, how often? *

Have you ever worked with a sleep consultant previously? If yes, when and what was the outcome? *

Your Childs Health & Behaviors

Was your child born earlier than due date? If yes, how early, and are they meeting developmental milestones for their age? *

Does your child ever bang their head while trying to fall asleep? If yes, how long does it typically last? Do they ever injure themselves? *

Does your child have any known allergies or medical conditions? Are they on any medications? *

Does your child snore, breathe with their mouth open or sweat significantly during sleep? If yes, please describe in detail. *

How would you describe your childs temperament? *

Easy going

Slow to warm up

Difficult

Mixed

Current Sleep Circumstances

Describe your child's sleeping environment for both day and night (crib in own room, room sharing with parents, sleeps in stroller only for naps)? *

Which of the following does your child rely on to be able to fall to or back to sleep? (Select as many as relevant) *

Parent laying with child until they fall asleep

Parent sitting with child until they fall asleep

Bedsharing/Cosleeping with parents

Parents return to room frequently until child is asleep

Rocked to sleep

Fed to sleep

Other

If answered Other above, please explain in detail: *

Have you tried any sleep training methods before with your child? *

Yes

If you answered yes to the last question, what method did you try? Why do you feel it did not work for your child? *

If your child wakes during the night, please describe your current approach to getting them back to sleep. Please be detailed. *

Please provide, in detail, additional information that will help me understand any specific needs you have for your child's sleep schedule or routines. Example: If you have late sports games that require a later bedtime or anything else that could potentially disrupt sleep schedules. *

Goals

What are you hoping to accomplish by the end of our time working together? What would "success" mean to you? *

Is there anything else you want me to consider as I create your personalized plan? *

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