Sleep intake Form

Your Name

Email Address

Your Child's Name

(For infants only) What is your baby's weight?

Please list all medications your child is currently taking

If so, did the doctor identify any medical issues that might contribute to sleep disturbance?

How long have your child's sleep difficulties occured?

What is your child's nap schedule during the day? Include duration of each nap.

If your child is nursing or bottle-feeding, how many times during a typical day? How many times at night?

How much active play time (such as practice walking, climbing play structures, etc.) does your child get per day?

What helps your child fall asleep? Do you typically hold or rock? Do they have any comfort items such as a pacifier or teddy bear that they sleep with?

How many hours does your child typically sleep during the night?

What time does your child typically lay down in bed?

What time does your child typically fall asleep?

What time does your child typically wake up in the morning?

How many times does your child wake up during the night? If they wake up, what happens?

Where does your child fall asleep?

List the names of caregivers who put your child to bed.

Does your child sleep alone or with a caregiver or sibling?

Do any siblings or other children live in the house? How old are they? Do they have any nighttime schedules or activities that overlap with baby's bedtime?

What is your parenting philosophy on letting your child cry? What duration of crying do you feel comfortable with?

Please describe any other concerns regarding your child that you'd like me to be aware of before starting sleep treatment.

Please describe what bedtime and your child's sleep look like right now on a typical night before starting sleep treatment.

Please describe what the ideal bedtime would look like for your child after completing sleep treatment.

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Sleep Intake Form

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