*In order for us to help and understand your needs and goals please fill out this intake form with as much detail as possible.

PARENT(S) DETAILS

Parent Name 1

Parent Name 2

Phone

Email

Your location?

CHILDS DETAILS

Childs Name

D.O.B and current age

Was your child born early? What is their corrected age?

Birth Weight

Current Weight

Have you had any weight gain issues?

Does your child have any medical conditions or do you have any current concerns?

Does your child snore?

Describe your child’s temperament

(eg. easy going, fussy, grumpy)

FEEDING

What Do They Eat?

(breast milk/formula/solids)

List A Typical Day Of Feeding

What time? Eg: 7am – milk feed 8am – breakfast (1 weetbix & ½ banana) 10am – milk feed etc… Including volumes where necessary

SLEEP ENVIRONMENT

Where does your baby sleep?

(eg. cot, bassinet, family bed)

Describe what your baby sleeps in?

(eg. sleeping bag, swaddle, blankets)

Does your baby require any sleep props?

(eg. dummy, comfort toy, blankey)

Describe sleep environment?

(eg. bright room, dark room, sound/music, is the room visually plain or lots of toys?)

NAPS

What time does your child wake of a morning?

If your child still naps, what times do they nap and for how long?

e.g Nap 1 – 9-10am Nap 2 – 12:30-2pm

How do you settle your child for naps?

Where does your child nap?

NIGHTS

Do you have a pre-bed routine?

If so, please explain what a typical evening routine may look like.

What time is bedtime?

How do you settle your child to sleep at night?

If your child wakes at night how do you resettle them back to sleep?

How many times overnight does your child still feed?

If formula fed, please include how much at each feed.

OTHER INFO

Are you hoping to see quick changes in your childs' sleep or are you happy to approach this process slowly and okay with seeing changes unfold over several weeks/months?

Briefly describe your parenting style.

- Do you prefer to follow routines, are you more flexible? - Are you happy to consider all settling techniques, or do you prefer non-controlled crying techniques?

Is your child stimulated by your presence or do they always calm down with your presence? Particularly in the sleep setting.

Do you have daily commitments that mean you have to leave the house at a certain time? If so, what time are these?

(eg. school pick-ups, day care leave for work) Please include if your child is in daycare and how many days per week

Has your baby gone through any major developments/ milestones recently?

(eg. walking, talking, rolling, sitting, crawling) Your blue book will have details on age appropriate developmental milestones if you are unsure.

GOALS

Please describe in detail what challenges you are currently facing with your child’s sleep and what you hope to achieve during our time working together?

How did you hear about us?

Thank you so much for taking the time to fill this form out, we look forward to helping you achieve your sleep goals!

CLIENT INTAKE FORM