Toddler Sleep Consultation

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, allergies or intolerances, etc.
Does your child display any of the following...

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.

Parenting Philosophy

Goals and Expectations

Signing of Agreement

THIS AGREEMENT made as of the signing of this contract B E T W E E N: BABY SLEEP 101 (hereinafter called the "Consultant") - and – the "Client".


1. The Consultant is a Family Sleep Institute certified Baby and Child Sleep Consultant operating under the name "Baby Sleep 101"; and
2. The Client wishes to engage the services of the Consultant.

NOW THEREFORE, in consideration of the mutual covenants and agreements hereinafter contained to be performed, the parties agree as follows:


1.01 The Client hereby engages the Consultant to perform services as provided in this Agreement.

1.02 This Agreement comes into effect on the day that the Client's payment in full is received by the Consultant.

1.03 The Consultant will have an initial consultation with the Client (the "Initial Consultation"). The Initial Consultation will be on the telephone or in person, depending upon the terms of the Support Package purchased by the Client, as set out in Article 2 of this Agreement.

1.04 If a Sleep Plan is part of the Support Package purchased by the Client, the Consultant may seek further information and pose questions to the Client. When the Consultant has received all of the information she requires from the Client, she will, within three (3) Business Days after the Initial Consultation, develop a Sleep Plan for the Client's child and will deliver the Sleep Plan to the Client via email. For the purposes of this Agreement, "Business Days" is defined as Monday through Friday, but not including days falling under the definition of "General Holidays" in subsection 21(1) of the Manitoba Employment Standards Code.

1.05 Following delivery to the Client of the Sleep Plan, the Client shall select a day within one week from delivery of the Sleep Plan on which the Sleep Plan will be implemented with the Client's child (the "Implementation Day"). The Consultant shall perform further consultation and follow-up services for the Client beginning on the Implementation Day, pursuant to the terms of the Support Package purchased by the Client, as set out in Article 2 of this Agreement.

1.06 This Agreement terminates in accordance with the terms of this Agreement.


2.01 The Support Package below is the Support Package which the Client has purchased and in accordance with which the Consultant will provide services. The terms of this Support Package are as follows:

Toddler Comprehensive Sleep Package
Includes: One hour telephone Initial Consultation; development and delivery of Sleep Plan; four 15 minute phone calls during the first seven days and one email exchange on days without scheduled calls after the Implementation Day (the first week); up to two email exchanges during days 8-14 following the Implementation Day (the second week); and Sleep Resource Guide upon completion of two week Toddler Comprehensive Sleep Package.

Cost:$ 349.00.

2.02 All telephone calls shall be pre-scheduled at times mutually agreeable to the Consultant and the Client. If the Consultant attempts to contact the Client at the scheduled time and does not reach the Client, the Consultant may attempt to call again but is not obligated to do so and shall be seen to have met her obligations under this Agreement insofar as that telephone call is concerned.

2.03 The Consultant shall answer support emails received before 5:00 p.m. Central Standard Time ("C.S.T.") on a Business Day on the day the support email was received. The Consultant may answer support emails received after 5:00 p.m. C.S.T. on a Business Day or at any time on a non-Business Day on the following Business Day.

2.04 Subject to Article 2.05, if the Client cancels a scheduled telephone Initial Consultation or follow up support call, within 24 hours before the scheduled appointment time, the Consultant may invoice the Client for a cancellation fee of $50. If the Client wants to request that a scheduled telephone consultation or follow up call be rescheduled, the Client shall send an email to the Consultant to request the change as far in advance of the scheduled appointment as possible. It is in the Consultant's sole discretion whether the appointment will be rescheduled.

2.05 If the Client's child becomes ill during the term of the Agreement, the Client must contact the Consultant as soon as is practicable to alert the Consultant to the illness. The parties may agree to pause the term of the Agreement until such time as the Client's child has recovered from the illness for a maximum of 3 weeks. The Client is responsible for updating the Consultant each week on the child’s health status. The Agreement may resume when the parties agree that the child has recovered, and this Agreement shall continue to govern the relationship between the parties as though it had not paused.


3.01 The Client hereby agrees to consult with the Client's child's pediatrician or family doctor (the "Health Care Practitioner") prior to the Implementation Day about the Client's intention to implement the Sleep Plan for the Client's child.

3.02 The Client hereby acknowledges that it is the Client's responsibility to ensure that the Client's child does not have health issues that are affecting the Client's child's sleep. The Client also acknowledges that it is the Client's responsibility to confirm with the Health Care Practitioner that the Client's child is healthy and that it is appropriate to implement the Sleep Plan, including if the Sleep Plan requires that there be no night feedings for the Client's child.


4.01 The parties hereby acknowledge that the information provided by the Consultant is not medical advice, nor is it intended or implied to be a substitute for medical advice. The parties hereby further acknowledge that the services provided by the Consultant are not medical services, nor are they intended or implied to be medical services.

4.02 The Consultant will use reasonable efforts to always provide accurate information and educational materials to the Client, but the Consultant makes no representations, warranties, or assurances with respect to the accuracy, currency or completeness thereof.

4.03 The Consultant shall not be liable for any loss or injury resulting from the Client's reliance on the information or services provided by the Consultant. The Consultant shall bear no responsibility for the content of any educational materials provided by the Consultant to the Client, or any loss or injury resulting from the Client's reliance on the educational materials.

4.04 The Client hereby agrees that the Client will not engage in any co-sleeping activity with the Client's child during the term of the Agreement. For greater clarity, "co-sleeping" means having the Client's child sleep in the same bed as the Client. For further clarity, co-sleeping is sometimes called "bed-sharing". The Client hereby acknowledges that the Consultant considers co-sleeping to be unsafe and that it puts the Client's child at an increased risk of injury and death. The Client further acknowledges that engaging in co-sleeping during the term of this Agreement has the effect of terminating the Agreement immediately.


5.01 The Consultant hereby agrees that she will hold in confidence all personal information received about the Client and the Client's child. The Consultant hereby agrees that she will not divulge any personal information about the Client or the Client's child without the Client's prior permission.

5.02 The Client hereby agrees that the Client will not share the Sleep Plan prepared by the Consultant for the Client's child with anyone, except for the Client's child's Health Care Practitioner, without the Consultant's prior permission. The Client hereby acknowledges that the Sleep Plan is intended specifically for the Client's child, and that it could be dangerous or otherwise inappropriate to attempt to implement the same plan with any other child, including a different child of the Client.


6.01 Either party may terminate this Agreement before completion of the services provided for in Article 2 by giving notice to the other party, but a refund of payment shall only be made in accordance with Article 7 of this Agreement. For clarity, if it appears to the Consultant that the Client or another individual in the Client's household is not following the Sleep Plan prepared by the Consultant, the Consultant may terminate the Agreement.

6.02 If the Agreement has not terminated earlier in accordance with the terms of this Agreement, the Agreement shall terminate upon completion of the services provided for in Article 2 of this Agreement.


7.01 Subject to Article 2.04, the Client may request a refund of payment up until such time as the Initial Consultation is complete. If such a request is made, payment will be refunded in full to the Client by the Consultant and this Agreement is thereafter terminated.

7.02 No refunds will be made after the Initial Consultation is complete, except at the sole discretion of the Consultant.


8.01 This Agreement shall be construed in accordance with the laws of Manitoba.

8.02 The validity of this Agreement shall not be affected for the sole reason that it exists only in an electronic format. For added certainly, this is consistent with the Manitoba Electronic Commerce and Information Act, C.C.S.M. c. E55. If the parties indicate their intention to enter into this Agreement by electronic means, that indication shall have the same effect as if the Agreement were affixed with the signatures of the parties.

IN WITNESS WHEREOF this Agreement has been duly executed by the parties this day of signing.

THE CONSULTANT: BABY SLEEP 101 Per: Joleen Dilk Salyn