Sleep Intake Form

Name

First Name

Last Name

Partner's Name (if applicable)

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Name

First Name

Last Name

Child's Due Date

Child's Date of Birth

Child's Age

Child's Current Weight

Have you discussed sleep with your pediatrician?

If yes, please explain

Is your child currently using a pacifier?

If so, during the day, night, or both?

Is your child in childcare outside of your home?

Does your child consume breastmilk, formula, or both?

How many times per day does your child get milk and if fed by by bottle, how many ounces per bottle?

Please describe your child’s temperament

Does your child have any medical conditions?

If yes, please explain

Does your child mouth breath or snore?

What is the biggest challenge for your family in regard to sleep?

Walk me through your child’s schedule during the day

What does a typical night look like from bedtime to 7 am?

Describe your child's sleep environment:

Where does your child sleep for naps and at night? Does s/he share a room with a sibling?

If your child wakes at night, how many times and how do you respond?

Who typically handles night waking?

What are your sleep goals for your family?

Have you read any books on sleep or tried any sleep training methods you have heard about?

If yes, please explain

Are there any sleep training philosophies that you prefer or are not comfortable with?

Please provide any additional information that may be helpful

Sleep Intake Form

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