Family Sleep Questionnaire

As the last step, please fill out this questionnaire. This will allow me to prepare your personalized sleep plan.

Child’s Name
Child’s Age
Mother’s Name
Father’s Name
Describe your child’s Bedtime Routine:
Describe your child’s Daytime Routine/Schedule if any:
Do you breast feed or bottle feed?
Where does your child fall asleep? Please describe the sleeping environment. (i.e. own bedroom; parent’s room; shared bedroom w/sibling; in a bassinet/crib/bed sharing/swing; on mom; black out curtains, sound machine, crib mobile/music on; other..)
What does your child wear to sleep?



How does your child fall asleep? / Any props used?





How many hours does your child sleep in a 24 hour period (please include naps)?
Please describe your child’s personality.




Have you ever tried any sleep methods or programs in the past? If so, which ones?
What led you to seek out a sleep consultant?
What are your feelings about crying?



What developmental milestones has your child accomplished?











Please add any additional information on what you are struggling with in regard to your child’s sleep, as well as any questions you might have, so that I may better understand and know how to help you. 
Thank you for submitting the form. In two days, you will receive your customized sleep plan at the email you specified.
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