New client Sleep Support Intake Form

Please note that unfortunately, there is not currently the option to save your progress and return to this form

I recommend taking photos of your little ones bedroom (one with the light on showing the whole room, and another standing in the room with the light off, door closed and curtains/blinds drawn to show darkness/light exposure) before getting started, so that you don't lose your progress (the form cannot be submitted without a photo upload)

This form should take approximately 10 -15 minutes to complete

Mother's first and last name

Father's first and last name

Mother's Email

Father's Email

Mother's Phone

Father's Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Child's name

Child's DOB

Month

Day

Year

Please list all of your children's names and ages

How did you hear about Jolly Good Sleep?

Does your child have any notable medical history?

Have you or your partner experienced any symptoms of post partum anxiety or depression?

Do you notice your child do any of the following?

Snore

Mouth breath

Neither

If yes, has this been evaluated by your paediatrician?

Yes

No

N/A

Do you notice your child display any signs or symptoms of, or have they ever been diagnosed with, any of the following?

Please expand on any selections made above (if "none of the above" was selected, please proceed to the next question)

Does your child attend any form of behavioral, physiological, psychological or developmental therapies - such as PT/OT etc? Please give full details. (if they do not yet attend any of these therapies but you believe that they should, please explain)

It can be helpful to share your sleep consulting journey and results with your child's pediatrician for their records. Would you like to share your Doctor's name and practice information?

Has your family suffered a significant life event or traumatic experience? (Please explain, as this can relate to sleep challenges and be greatly helpful to your child's assessment)

Describe your child's general mood, does this change throughout the day?

What (if any) are your work and/or childcare arrangements?

What (if any) are your family's late afternoon/early evening commitments (such as sports) that could encroach on bedtime? (please list day, time and duration of your schedule commitments)

Please detail your little one's feeding schedule, how and when are they fed? (Solids/breast/formula)

How involved do you want to be in your child's process for falling and returning to sleep? (After a soothing bedtime routine, is your comfort level to physically help them fall asleep? Do you want them to fall asleep independently?)

Have you tried any sleep strategies or read any books in an effort to improve your child's sleep?

What sleep strategies have you heard of that you agree or disagree with, does the whole parenting team agree/disagree?

Tell me a little about your child's sleep habits from birth onwards

Is your child able to self sooth? if so, how?

What time does your child wake for the day, are they happy? Is this time consistent?

What is your child's current nap schedule/routine (please list average nap start time, how they fall asleep and duration for each nap)

For naps, Do you put them in bed awake, drowsy or fast asleep?

What is your child's current bedtime schedule & routine? (please list average routine start time, what takes place during the routine, how they fall asleep and the time that they are put to bed)

How is your child's mood as you approach bedtime?

Does your little one have a big bedtime battle or protest and if so, how do you respond?

What are your little ones potty habits throughout the night, are they potty trained?

Tell me about the nighttime, do they sleep through the night? If not, how often are the wakings and how do you respond to them?

Is your little one waking to feed at night? If so, what does the time tend to be, how do they get back to sleep?

Who in the parenting team usually handles nap time, bedtime or night wakings?

Which baby monitor do you use?

Which sound machine do you use? Please describe sound and light settings during sleep

Does your child's sleep environment change in response to night wakings or crying? e.g: if they are having a prolonged period of crying, do they/do you move them from their bedroom to yours?

Upload images of your little one's room, both with the light on and a separate image with door closed, window dressings closed and the light off

File upload

Please tell me about your ultimate sleep goal for your family, is everyone on the parenting team committed to achieving this goal?

When thinking of working together to achieve your family's sleep goal, what, if anything, do you think you may find the most challenging?

When you achieve your sleep goal, how will that benefit your family, how might life change for you?

What activity or date night spot are you most looking forward to enjoying once everyone's sleeping well?

Is there anything else you think is important for me to know?

Parent Signature

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New client Sleep Support Intake Form

Charlotte, NC USA

Terms & Conditions

Privacy Policy

HIPPA Policy

​New client Sleep Support Intake Form

Charlotte, NC USA

Terms & Conditions

Privacy Policy

HIPPA Policy

New client Sleep Support Intake Form