Intake Form

Please fill out the form below with as much detail as possible. The information you provide is kept confidential and is only used to assist with your consultation, sleep plan and support time.

Child's Name
Please list any current or previous medical issues including reflux, food or environmental allergies, etc.

Parent's Information

Parent 1 Name
Parent 2 Name

Contact Information

Please list the best option to reach you at.

Child's History

Was your child considered colicky as a newborn?
Were your child's sleep issues discussed?

Child's Daily Routine

How long does it take your child to fall asleep at bedtime?
Can your child fall asleep without your help or presence?
What does your child use to help them fall asleep? Please check all that apply.
What sleep associations does your child have, if any?
When you put your child to bed, please rate their level of wakefulness, with 1 being wide awake and 5 being in a very deep sleep.
How many times does your child wake each night? Include night feedings if applicable.

Child's Sleeping Environment

Please rate the level of darkness in your child's room; 1 being bright and sunny, and 5 being pitch black.
For example; upstairs at the end of the hallway, borders the washroom, parents room or siblings room, main floor next to living room, etc.

Parent History

Parenting Philosophy

Goals and Expectations