Intake Form

Your Name

Child's Name*

Child's Date of Birth*

Child's Due Date*

What are your sleep goals for your child and your family?*

Daily Schedule

What time does your child typically wake up?

How many naps per day, what times, how long?

How long does it take him/her to fall asleep for naps?

What time does your child go to bed?

How long does it take for him/her to fall asleep at bedtime?

During the night, what time(s) and for how long is he/she awake?

If your child wakes for any other reason at night, how often and how do you respond?

Sleep Environment

Briefly describe the sleep environment where your child sleeps for naps and at night

(including light, crib, bed, noise, temperature, room sharing):

Sleep Routines

Describe your child’s nap and bedtime routines
(please include whether you swaddle, whether your child uses a lovey/pacifier/stuffed animal):

If your child is in school or day care, does your child sleep at these facilities? If so, at what time and for how long?

Please list any other care givers for your child and the times they take care of your child.

General Background Info

Describe briefly your child’s sleep habits from birth on:

Please describe your child’s temperament during the day:

Does your child mouth breath or snore?

yesno

Does your child have any medical conditions we should be aware of?

yesno

If yes, please explain:

Have you read any books on sleep or tried any sleep training methods you have heard about? Which ones?
Are there any sleep training philosophies that you prefer or are not comfortable with?

Please provide any additional information that may be helpful:

Who is your pediatrician?

Pediatrician's address

Street Address

Pediatrician's Phone

How did you hear about us?