Intake Form for Sleep Consultation Client InformationName First Last Email PhoneYour Child's InformationChild's Name First Last Child's Age Was your child born early, on time or late? Any special difficulties with birth?Any difficulties with feedings postpartum?Does your child... Snore Mouthbreath Both Daily ScheduleWhat time does your child wake up in the morning? : Hours Minutes AM PM AM/PM When your child wakes up they are... Happy Crying Other Approximate Nap Start Time : Hours Minutes AM PM AM/PM Approximate Nap Length Approximate Nap Start Time : Hours Minutes AM PM AM/PM Approximate Nap Length Approximate Nap Start Time : Hours Minutes AM PM AM/PM Approximate Nap Length Where does your child sleep for naps? Where does your child sleep for bedtime? During the day my child is typically ... (1=happy, 5=cranky) 1 2 3 4 5 Bedtime is usually around what time? : Hours Minutes AM PM AM/PM Do you have a bedtime routine? Yes No If Yes, please describe:How many times at night does your child wake?Who typically handles the night wakings? Mom Dad Other If your child needs feedings during the night: How many does he/she need?What do you do to get him/her back sleeping and how long does it take?Is your child in school or daycare? Yes No What is your ultimate sleep goal? Please describe in detail.Please add anything else you would like to share or feel we should know.
