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Client Intake Form
Name
Your Full Name:
*
Baby's Full Name:
*
Email Address:
*
Phone Number:
*
Baby's Age:
*
Baby's Birth Date:
*
Was your baby premature?
Yes
No
Corrected Age:
Baby's Birth Weight:
*
Baby's Current Weight:
Baby's Sleep Environment:
*
Please describe baby’s sleep environment. ie cot, co sleeping, white noise, is room brightly lit or dark, are you room sharing
Baby's Sleep Routine:
*
Please describe baby’s nap and bedtime routine. Please include if swaddled, using
Baby's Feeding Information:
*
Briefly describe baby’s eating. Brest feeding, formula or both and solids. How often and amounts if applicable.
If Breastfeeding, please list any concerns you may have:
Does your child snore?
Yes
No
What time does your child typically wake in the morning?
*
What time does your child go to bed at Night and how do you settle them?
*
If baby wakes at night how do you settle them back to sleep and how often do they wake?
*
Briefly describe the number of naps per day, the times, length and how you settle baby for a nap?
*
Do you or your child have any health conditions or current health concerns?
*
Yes, if yes please provide a brief description
Please describe in detail what exactly the sleep problem is that you are experiencing?
What are your sleep goals for your child and family?