Intake Questionnaire

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INTRODUCTION

Welcome to Services at North Shore Sleep Co. Please fill out this form to the best of your ability with as much detail as possible. The more information you provide, the more accurate I can be in providing recommendations and strategies to help you and your little ones get some much needed sleep. Feel free to add any additional information that will help me get to know your family and your little one

GENERAL CLIENT INFORMATION

Parent's Name*

First Last

Email*

Enter Email Confirm Email

Phone*

Address*

Street Address Address Line 2 City ZIP / Postal Code

Child's Name*

First Last

Child's Date of Birth*

What are your sleep goals for your child?*

Are you the primary caregiver for your child? Please list any other caregivers and describe their involvement in caring for your child.*

SCHEDULE

What time does your child wake up for the day?*

What time do you put your child to bed?*

Does your child nap during the day? # of Naps, duration and at what times?*

How long does it take for your child to fall asleep?*

How often does your child wake up during the night and for how long? How do you respond?*

SLEEP ENVIRONMENT

Does your child bed share (sleep in your bed), co-sleep (sleep in a separate crib in your room), or sleep in his or her own room?*

Briefly describe your child’s nighttime sleep environment. Crib, room temperature, lighting, sleep clothes, noise etc*

Briefly describe your child’s nap environment if different from above*

Please give a brief recap of your Bedtime routine (what do you do to help prep your child for bedtime)*

EXPERIENCE WITH SLEEP TRAINING

Have you tried sleep training in the past? If yes, please describe and explain what was or wasn’t successful.*

PERSONAL AND MEDICAL HISTORY

How would you describe your child’s mood during the day on average?*

Does your child have a Doctor/ Pediatrician?*

Does your child or has your child previously had any diagnosed medical conditions or concerns? If yes, please describe.*

Is your child being actively monitored for any medical conditions or concerns? If yes, please describe.*

What services are you interested in?*

How did you hear about us?*

Did someone refer you?*

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