Parent(s) Name(s) and pronouns (she/her, he/him, they/them):

How do you refer to yourselves as parents? (eg. Mommy, baba, papa, etc)

Your age

Name and age of children who live in your household (Place an asterisk next to the child/children whose sleep concerns we will be addressing):

Other caregivers who will be involved in your child's sleep work (name and relationship to child):

Are the other individuals on board with your plan to address your child's sleep? (It is crucial that this be discussed before our initial consultation)

Pediatrician / Family Doctor Contact Info (Name & City)

Have you spoken to your paediatrician about your sleep concerns? If so, what did they suggest?

Have you previously worked with a sleep coach? If so, could you briefly tell me about your experience?

Have you read any sleep books? If so, which ones?

Child's Date of Birth

Was your child born full term (40 weeks)?  If no, born at how many weeks?

Has it been challenging to build your family?

Were there any complications during labour or in the newborn period?

Is your child taking any medication currently?  (Prescription or over the counter)

What is your child's current weight? (Please share percentile if known)

Do you or your pediatrician have any concerns about your child's weight gain?

Does your child have any allergies?

Would you characterize your child as being "colicky" or "refluxy"? If yes, has your child received any diagnoses or been prescribed medication?

Are there any other past or current medical or developmental problems?

Does your child have Asthma?

Does your child get frequent ear infections?

Does your child have a frequently or constant stuffy nose? (Even if not actively sick)

Is your child a restless sleeper?

Does your child snore?

Is your child:

If Breastfed: Do you experience nipple pain while latching or throughout your breastfeeds?

If Breastfed: Have you noticed a compressed nipple shape when your baby unlatches?

If Breastfed: Do you experience burning/throbbing in the nipple or breast after/between feeds?

If Breastfed: Does your baby act satisfied between feeds? Or do you notice constant hands to mouth, an inability to be put down after a period of calm in your arms, or frequent rooting or sucking (such as needing a pacifier) even after a feeding has been finished?

Will your baby only fall asleep when their nervous system is occupied (pacifier, swaddling, in a swing, intense bouncing or rocking)?

Is your baby gaining weight well, and having at least 6 pees and 1 poo per day?

Has your baby started solids?

If so, at what age?

Approximately when did your child reach the following milestone (if applicable):

Rolling Over

Approximately when did your child reach the following milestone (if applicable):

Sitting Unsupported

Approximately when did your child reach the following milestone (if applicable):

Crawling

Approximately when did your child reach the following milestone (if applicable):

Pulling to Stand

Approximately when did your child reach the following milestone (if applicable):

Walking

Please add any detail about your child's sleep location here.

If out of crib, for how long now?

Does the sleeping location change during the night?

Does your child share a room with anyone? Who?

If you have other children, do they go to bed at the same time?

Are you concerned your child may try to climb out of their crib? Have they done this before?

Are you worried that making changes to your child's sleep routine might disturb others in your household?  Who and why?

Are your concerns with your child's sleep new or ongoing since infancy?

How would you describe your child's temperament?

Does your child suck their thumb or fingers?

Does your child use a pacifier?

If so, are they able to replug it themselves?

Does your child sleep with a security object or lovie?

How do you get your child to sleep for naps and bedtime? Describe the routine, including how long before bedtime it is started.

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

Are there rituals or certain things that your child does to self-soothe?

How do you respond if/when your child wakes up at night?

Is there a pattern to your child's night wakings?

Does your child appear sleepy during the day but not take a nap?

Please outline a typical 24 hour schedule with your child in detail, from waking up to through the night. Please include all feeds, as well as a general idea of activities while your child is awake.

How would you describe your current sleep situation?

How is your appetite?

Are you able to sleep while your child sleeps?

Are you having troubling or scary thoughts?

Do either of you feel like you could possibly be suffering from postpartum depression or anxiety? Do you feel "off", not like yourself, in a fog, etc?

What is the ultimate outcome you and your child's other caregivers would like to see in regards to your child's sleep habits by the end of our work together? Please be specific in regards to location of sleep, amount of night feeds you are willing to keep, etc...

Have you tried anything to address your sleep concerns in the past?