Sleep Training Intake FormPlease fill out in as much detail as possible. Name * First Name Last Name Email * Phone * (###) ### #### Age of baby/child? 1) On average, what time does your child wake up in the morning? 2) What is your child’s current daytime nap schedule? Include the time your child goes down for each nap, and the duration of each nap 3) On average, how many accumulative hours of daytime sleep does your child receive during naps? 4) Does your child have a nap time routine? If so, what does it look like? 5) What clothing does your child sleep in for naps? 6) What is the set-up for sleep space environment during naps? 7) Does your child have a bedtime routine, and if so what does it look like? 8) What does your child wear to bed at night? (e.g. footie pajamas, sleep sack) 9) What does your child’s bedtime sleep space environment look like? 10) What if any is your child’s bedtime? 11) How many times a night does your child wake up and how long do they remain awake before falling back asleep? 12) What is the longest period of time your child sleeps at night, and on average at what time does this occur? 13) On average, what is the cumulative number of hours you believe your child sleeps, from the time you put them down at night to the time they wake up in the morning? 14) What sleep props does your child require to fall asleep and stay asleep? A sleep prop is anything used to help fall asleep and/or stay asleep. Check all that apply. Breast-feeding Bottle feeding Pacifiers White noise machine Stuffed animal Blanket Toys Singing Rocking Bouncing Other 15) Please describe your child’s personality type. 16) Please describe any physical and developmental milestones your child has reached. Examples: rolling, crawling, walking, bringing objects to mouth, tracking objects with eyes, pulling to stand, walking, etc. 17) Please describe your feelings on crying as it pertains to sleep training. Keep in mind that a minimal amount of crying is necessary in the process of sleep training. 18) In detail, please provide any and all other information you feel is important for me to know as your Sleep Consultant so I may better serve you. Thank you! I will be in touch with you shortly.
