I'm thrilled to suppor t you and your child wi th sleep. To get star ted, I'd love to learn more about you. Please fill out this form as completely as possible.

PERSONAL INFORMATION

First Name

Last Name

Phone Number

Email Address

Address

Your Profession & Hours of Work (if applicable)

YOUR FAMILY

Your Partner's Name

Your Partner's Profession & Hours of Work (if applicable)

Does your child have any siblings? If so, what age?

Does your child have any other caregivers?

Does your child attend daycare or preschool? If so, what days/hours and where do they sleep?

CHILD’S INFORMATION

Child’s name

Date of Birth

Age

Gender

Weight

Was your child born prematurely? (# of weeks)

Any Health Concerns or Medical Considerations

Any Known Allergies

Current Medications

FEEDING INFORMATION

Please share about your child’s breastfeeding and/or bottle-feeding patterns, as well as whether you have introduced solids foods. For example, when does your child have a breastfeed and/or bottle during the day and at night, how many ounces, any pertinent feeding history (e.g. latch issues, supply challenges, etc.).

SLEEP ENVIRONMENT

Please select the following items you use for your child’s sleep:
Soother/PacifierNightlightSound MachineLovey or Comfort ObjectSwaddle or Sleep SackMerlin SuitBlackout BlindsOther

Where does your child sleep? (i.e. bassinet, crib, in arms, toddler bed, your bed, car, stroller, etc

YOUR SLEEP GOALS

What are your goals for your child’s sleep?

YOUR SLEEP CHALLENGES

What challenges are you facing with your child’s sleep?

OTHER SLEEP INFORMATION

What sleepy cues/signs does your child show when they are tired?

How does your child fall asleep for naps? At bedtime? Through the night?

Do you have a naptime routine? If so, please explain

Please tell me about your child’s naps. How many naps a day, are naps difficult, what happens for naps, etc

What happens throughout the night? (i.e. how many night wakes, what happens at night wakes, etc.)

ADDITIONAL NOTES

How are you coping with lack of sleep? Is there anything you would like me to know about you and how I can support you?

Please share any other thoughts, concerns, or questions you may have!

SLEEP ASSESSMENT

Please t rack a full day of your child’s actual sleep schedule. Thank you!

Date

Day
MondayTuesdayWednesdayThursdayFridaySaturdaySunday

What time did your child wake up in the morning?

How long was your child awake for before their 1st nap? What time was their 1st nap at?

How did your child fall asleep for their 1st nap, and how long was the nap? What time did they wake at?

How long was your child awake for before their 2nd nap? What time was their 2nd nap at?

How did your child fall asleep for their 2nd nap, and how long was the nap? What time did they wake at?

How long was your child awake for before their 3rd nap? What time was their 3rd nap at?

How did your child fall asleep for their 3rd nap, and how long was the nap? What time did they wake at?

How long was your child awake for before their 4th nap? What time was their 4th nap at?

How did your child fall asleep for their 4th nap, and how long was the nap? What time did they wake at?

When did you begin bedtime routine? What time did bedtime routine start?

How did your child fall asleep at bedtime? How long did it take them? What time did they fall asleep at?

What happened through the night? What time and how long were the night wakes? What happened at the night wakes?

Is there anything else you would like me. to know about this day and night?

How was your child’s feeding this day and night?