Name
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First Name
Last Name
Email
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Phone
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Other Parent's Name
First Name
Last Name
Child's Name
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First Name
Last Name
Child's Birthday
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MM
DD
YYYY
Was your child born prematurely?
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Child's Birthweight
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Please describe what your child sleeps in (i.e., long sleeve pajamas, swaddled, etc.)
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Does your child have any sleep props, such as a pacifier, lovey, white noise machine, etc.? This can also include needing to be nursed, rocked, or held to sleep.
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Please describe your child's sleep environment in as much detail as possible.
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Where in the house does your child typically sleep?
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Do you work outside the home?
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Does your child attend daycare or are they cared for someone other than you during the week?
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Does your child snore?
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What does your nap time routine look like? How are you settling your child down for their naps?
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What does your child's bedtime routine look like? How are you settling them down for the night? What time (on average) is bed time?
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If your child wakes up at night, what steps do you take to settle them and how often do they wake?
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What have you done so far to solve your child's sleep struggle? How did it go?
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Does your child have any medical problems, such as sickness or allergies?
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Please briefly describe your parenting style.
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As of this moment, would you prefer a more gradual approach to sleep training, or would you rather jump in with both feet and try a more direct approach?
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Has your child gone through any major developmental changes or hit any milestones recently?
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Finally, please describe in detail exactly what the sleep problem is that your child is experiencing and what you'd like to see change.
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Name
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First Name
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