Client Intake Form

Intake Information: Child

How did you hear about Sleep Tight Solutions? *

Parent's Full Name: *

Parent's Email: *

Parent's Phone Number: *

Name and contact number of your child’s pediatrician? *

Please list all of your children by order of birth using their birth-dates starting with the first child.

Who is the child we are helping today? How old are they? Were they born on time, early or late? *

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

Does your child snore or mouth breath? *

What time do they wake for the day? *

Does your child nap? If yes, how many times per day? Please list the time and duration of the naps? *

What time is your child’s bedtime? Please describe your child’s bedtime routine, including if you use a swaddle. *

Does your child experience night waking’s? If yes, please describe how you handle them. *

Does your child wake for feedings? If yes, how many times? What time do these waking’s typically occur? Who deals with these waking and what do they do? *

Please describe your child’s temperament during a typical day. *

Intake Information: Child’s Sleeping Environment & Current Schedule

Where does your child sleep? Please list all of the environments that your child typically sleeps in below; (i.e. crib, family bed, stroller, car, etc.) *

Please describe the room that your child sleeps in; do you have curtains or shades on the windows? Please rate the level of darkness in the room where your child goes to sleep- 1 being bright and sunny, and10 being absolutely dark. *

Does your child have a lovie, blanket, pacifier, or stuffed animal that they use to fall asleep? If yes how is it incorporated into the bedtime routine? *

When you put your child to sleep please describe their state of wakefulness from 1-10, 1- being wide awake and alert, and 10 being in a very deep sleep. *

Please list your daily schedule below; include wake time, feedings- both milk or formula and solid food, naps, playtime or outings, and bedtime; Be as specific as possible. *

Intake Information: Parent History and Family Philosophy

Has your family experienced any loss or trauma? Was your child affected by this? *

Have you read any books on sleep; if yes which ones? *

Are there any sleep philosophies you agree with? If yes, please explain why. *

Are there any sleep philosophies that you are uncomfortable with? If yes, please explain why. *

Is everyone in the household committed to your child getting restful and restorative sleep? *

Is your child in daycare or school? Who is their primary caretaker, or who spends the most time with the child? Will other caretakers follow your child’s sleep schedule when the primary caretaker is away? *

Intake Information: Goals for the child and family

Please describe in as much detail as possible what your ultimate goals are for both your child and yourself and your family. *

Please add anything that you would like to share or feel we should know.

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