Client Intake Form

To allow enough time to prepare you consult plan prior to your scheduled appointment, please complete this form within 48 hours of payment.

Your Full Name:

Baby's Full Name:

Email Address:

Phone Number:

Baby's Age:

Baby's Birth Date:

Was your baby premature?

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?

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?