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Child Information

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Please confirm your email address (Required)

What is your child's first name? (Required)

What is your child's last name? (Required)

How old is your child? (Required)

What is your child's date of birth? (Required)

How much does your child weigh? (Required)

If bottle-fed, how many ounces does your child drink per day? What brand of bottle do you use? What size nipple does he/she use?

What kinds of foods do you feed your child? (Required)

Have you had any issues with feedings? If so, please explain.

Does your child have any food allergies or sensitivities?

How much milk does your child drink throughout the day?

General Information

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Parent's First Name (Required)

Parent's Last Name (Required)

Partner's First Name

Partner's Last Name

Address (Required)

Address 2

City (Required)

Zip Code (Required)

Country (Required)

What is your occupation? Do you work in the home or out of the home?

What is the occupation of your partner? Does he/she work in the home or out of the home?

Does your child have any siblings? What are their names and ages?

Have you read any books about infant sleep? Have you tried any suggestions from these books in the past? (Required)

What is your family's schedule? (Please include school times of siblings, baby classes, etc.) (Required)

What are your fears, doubts, worries, or concerns about this process? (Required)

Who can I thank for referring you? (If applicable, please enter 1 specific person.)

Is your child in a daycare or with other caregiver’s care at any point during the week?

Health Information

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Have there been any health issues or concerns and are they being treated or have they been resolved? (Required)

Does your child snore or is he/she a heavy mouth breather? (Required)

Is your child on any medication? (Required)

Have you spoken to your doctor about your child's sleep difficulties? (Required)

What developmental milestones has your child met? What developmental milestones is your child working on? (sitting up, crawling, standing, walking, talking, etc.) (Required)

How does your child handle transitions from one activity to another?

Does/Did your child have a lip or tongue tie? If yes, was it revised?

Does/Did your child have reflux? If yes, do you feel it is well-controlled?

Sleep Information

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Please describe the room your child sleeps in. (Where is the crib/bed? What is in your child's bedroom and in your child's crib? Do you have curtains/shades on the window? Do you have any lighting on in the room when your child is sleeping? What is the temperature in the room? Do you have any sound going while your child is sleeping? Does a pet sleep in the same room as your child?etc.) (Required)

What time does your child currently wake to start his/her day? (Required)

What time would you like your child to wake to start his/her day? (Required)

What happens at this time? Is he/she given a bottle, breastfed, start with solids, etc.? (Required)

What signals do you notice your child gives when he/she is tired? (Required)

If your child naps --

What time of day does the first nap usually occur and where does it take place?

How do you get your child to sleep for this first nap? (Required)

How long does this nap last? (Required)

What time of day does the second nap occur?

How does your child fall asleep for this nap?

How long does this nap last?

Is there a third or fourth nap during the day or early evening?

How does your child fall asleep at this time?

What time do you start getting your son/daughter ready for bed? (Required)

What do you do with your child when getting him/her ready for bed? (i.e. bath, brush teeth, sing songs, read stories, play a game, etc.) (Required)

What time does your child actually fall asleep at bedtime? (Required)

How does your child fall asleep at this time? (Required)

What happens during the night? (best AND worst case scenarios) (Required)

What does your child wear when sleeping? (sleep sack, swaddle, sleep suit, etc.) (Required)

Was there a time your child slept well and then things changed? (Required)

Does your child use anything external to help get to sleep? (i.e. pacifier, rocking, mobile, music, bottle/breastfeeding, mom or dad, etc.) (Required)

What are your ultimate sleep goals? What would you like to see happen? (Required)

Have you ever or are you currently experiencing post-partum depression/anxiety?

Is there anything else you would like to share with me that you think I should know before we begin (i.e. recent traumatic life experience, unique family situations, cultural considerations, etc.)?

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