Date
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MM
DD
YYYY
Name
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First Name
Last Name
Email Address
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Phone
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I acknowledge that in the beginning, teaching my baby correct sleeping habits requires strong levels of commitment. I am prepared for 1-3 weeks of hard work while the new skills are being taught and my partner or support person is on board with these changes.
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I acknowledge that in the beginning of the sleep training process I will need to be organised in my daily life and have minimal commitments, so I can focus 100% on teaching my baby to sleep better.
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I acknowledge that there may be some crying involved during the sleep training process.
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I acknowledge that I will need to be consistent throughout the sleep training process and follow the guidelines of the sleep training method I have chosen. I have ensured that my baby's sleep environment is safe and in line with the SIDS guidelines.
Baby's Name
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First Name
Last Name
Baby's Date of Birth
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Baby's Age
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Baby's Birth Weight
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Baby's Current Weight
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Was your baby premature?
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Yes
No
If your baby was premature, what is his/her corrected age?
Have you tried sleep training before? How did it go?
What is your baby's sleep issue?
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What would you like to work on regarding your baby's sleep?
What time does your baby settle to sleep at bedtime?
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What time does your baby wake in the morning to start the day?
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How do you settle your baby for naps and at bedtime?
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Does your baby snore or sweat during sleep?
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Yes
No
Is your baby swaddled?
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Yes
No
How many layers of clothing does your baby sleep in? What materials are these made of?
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What does your baby sleep in? What materials are these made of?
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(e.g. sleeping bag, swaddle, blankets)
Does your baby use a dummy or have a lovey/comforter?
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Yes
No
Does your baby have any sleep associations?
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(e.g. feeding, rocking, sucking, driving, wearing)
How long has this sleep association been happening?
What is your baby's sleep environment like?
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(e.g. dark, light, white noise, mobile over cot)
Is there a night light in the room? What colour is this light?
Does your baby have siblings? If so, what are their ages?
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Are their siblings good sleepers?
Please describe a typical day.
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Starting at 7am until bedtime. Include: naps, and how long it takes to settle to sleep, milk feeds and solids timing and volumes, outings.
Please describe a typical night.
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Starting at bedtime until 7am. Include all wake ups, what do you do at these wakes ups, what time baby returned to sleep.
Any feeds given and volumes of feeds?
How is your baby fed?
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Breastfed
Formula Fed
Mix Fed
If bottle fed, please list volumes and timings of feeds over a 24hr period.
If breastfed, please list the time spent at breast (per feed) and how often these feeds take place over a 24hr period.
List all types of solid foods your baby is having.
If applicable
What times of the day are you offering these solids?
If applicable.
Volumes of solids?
(e.g. 2 tablespoons, 1/2 cup etc)
Did or does your baby suffer from colic or reflux?
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Yes
No
Does your baby attend daycare? Or is your baby cared for by someone other than yourself?
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If yes, what days and times?
Does your baby nap at daycare
Yes
No
If your baby naps at daycare, what time is this nap and for how long?
How does daycare (or guardian) settle your baby to sleep?
How long is the journey to daycare?
Is your baby reaching age appropriate milestones?
(e.g. smiling, rolling, crawling etc)
Has your baby starting doing anything new recently?
(e..g rolling, crawling, standing, daycare).
Please describe your baby's temperament.
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(e.g. easy-going, fussy, grumpy, sensitive).
Does your baby have any medical issues?
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Or do you have any health concerns lately?
What are your thoughts around crying?
Or how do you feel about your baby crying?
Please describe your parenting style.
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(e.g. go with the flow, routine driven, a little bit of both)
Do you have any commitments that require you and baby to be out of the house?
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(e.g. school run)
What time does your partner get up for work?
Do you have a second job outside of the home?
Please provide any other additional information you feel might be relevant.
How did you hear about us?
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Google
Facebook
Instagram
Word of mouth
Something else