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Sleep intake form
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Indicates required field
Parent Name
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First
Last
Baby's Name
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First
Last
Email
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Parent Name
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First
Last
Phone Number
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Today's Date
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What package are you using?
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Please attach a photo of your child (or send it to Lynne)
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Max file size: 20MB
What is the biggest sleep challenge in your family?
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What are your sleep goals for your baby and your family?
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Share something sweet or funny your baby has done recently.
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Baby's Due Date
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Baby's Birth Date
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Baby's Current Age
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Date of baby's last pediatrician appointment
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Is your baby experiencing any illness right now?
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Is your baby prone to ear infections?
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Does your baby have reflux, GERD, allergies, or frequent spitting up?
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Has your baby been diagnosed with colic?
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Does your baby have any medical conditions?
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Baby's height and weight
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Does your baby take a pacifier?
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How is your baby fed?
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How often and how long does your baby eat from nursing/bottle?
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Is your baby eating solids? If so, how often and how much?
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Is your baby currently taking any medications?
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Is your baby currently in childcare outside your home?
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If yes, what are the sleeping conditions like, and how does your baby do napping there?
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My baby currently sleeps (check all that apply)
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In a swing
In a crib
In a bassinet or pack-n-play
In my arms
In a swing/bouncer
In the same bed as parents
Other (add your own)
Is your bedroom on the same floor as baby's?
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Yes
No
Does your baby share a room with a sibling? Or will your baby at some point soon?
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Where does your baby nap?
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Does your baby snore?
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Yes
No
Describe your baby's sleeping environment
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Bright light
Some light
Mostly dark
Completely dark
Is your baby swaddled, or using a swaddle transitional product? If so, which one?
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In what position does your baby sleep?
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Describe the room your baby sleeps in (sound, light, temperature)
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Which of the following do you use to help your baby fall asleep (check all that apply)
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Nursing/feeding
Shushing
Patting
Being held
Pacifier
Walking
Car rides/baby carrier
Baby sleeping with you/holding baby
Rocking
Other
Describe your baby's temperament and personality
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Is your baby easily adaptable?
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What developmental milestones has your baby achieved? (Check all that apply)
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Rolling over
Sitting up
Crawling
Pulling up
Walking
Do you put your baby to bed
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Fully asleep
Drowsy and awake
Fully awake
Describe your baby's mood upon waking from naps and nighttime sleep
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What time does your baby wake for the day?
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What time do you WANT (or need) your baby to wake for the day?
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What time does your baby go to bed at night?
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What time do you WANT (or need) your baby to go to bed at night?
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Which words would you use to describe your baby? (check all that apply)
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Usually happy
Stubbord
Sensitive
Aware/observant
Needy/clingy
Fussy
Most adorable baby ever born
Does your baby wake in the night? If so, how many times?
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Who cares for the baby during night wakings, and what does that person do?
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How many naps does your baby take each day? How long do the naps usually last?
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Describe your baby's general daily schedule (wake time, naps, eating, bedtime)
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Describe your nap and bedtime routines
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Do you want to wean from night feedings?
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Has your doctor given the OK to wean from night feedings?
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Has your family gone through any changes, transitions, travel, or schedule changes recently?
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Has your doctor given the OK to begin sleep training?
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Have you tried any sleep training techniques before? If so, how did they go and how did you feel about them?
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Have you read any sleep training books before or followed any plans? If so, how did you feel about them?
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If both parents are involved, are both parents on board with sleep training?
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How do you feel about letting your baby cry? How long would you feel comfortable letting your baby cry?
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Do you want your baby to sleep in the same room as you, or your baby's own room?
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Do you have any other kids? If so, what are the ages?
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When do you want to begin implementing sleep training?
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Are you traveling any time during the sleep training period (2 weeks)?
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How do you like your coffee?
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Just for fun =)
Are there any specific ways I can be praying for you throughout this process?
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Do you have any other questions or anything else I need to know?
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