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):

Please list any other caregivers who will be involced in your child's sleep work (name and relationship to child):

Are 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 (or other health care professionals) 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 or parenting books? If so, which ones?

Child's Date of Birth

Was your child born prematurely?

Has it been challenging to build your family?

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

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

Would you have characterized your child as being "colicky" or "refluxy" when they were babies?  Were they ever given any formal diagnoses or medication?

Does your child have any allergies?

Does / has your child had any developmental concerns?

Does your child have Asthma?

Does your child get frequent ear infections?

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

Is your child a restless sleeper?

Does your child snore?

Is your child:

Can you provide details regarding your child's ongoing breastfeeding / bottle feeding if applicable?

(How often? What times of day?  And how do you feel about it?)

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

Do you have any concerns about your child's eating?  (Picky eater? Constipated?)

Approximately when did your child reach the following milestone:

Crawling

Approximately when did your child reach the following milestone:

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 evening / 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?

Is your child potty trained?  (Day? Night?)

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

How would you describe your child's temperament?

Does your child use a pacifier?

If so, please give more detail: How frequently?  For sleep or only during the day? To fall asleep or for the entire night?

Does your child sleep with a security object or lovie?

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

How long does it take your child to fall asleep?

If bedtime is a struggle, what do your child's usual stalling tactics involve?  (eg. running around the house, wants a snack, "one more book", etc)

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

Does your child come visit you in the middle of the night?

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

Is there a patterns 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.

How would you describe your current sleep situation?

How is your appetite?

Are you able to sleep while your child sleeps?

Are you having any 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?

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