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

Child Sleep Questionnaire

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Child's name *

Child's Age *

Mother's Name *

you child's for

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? *Select from dropdownBreast FeedBottle 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? *

• Swaddle
• Sleep Sack
• Pajamas

How many hours does your child sleep in a 24-hour period? (Please include naps) Slide for number of hours

Selected Value: 0

Please describe your child's personality: *

• Calm, Relaxed, Content, Playful
• Strong-willed, Stubborn
• Fussy, Cranky, Restless, A lot of Separation Anxiety
• Crying, Anxious, Lack of Contentment

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? *

• Crying does not bother me
• I can tolerate some crying
• I cannot stand hearing my child cry

What developmental milestones has your child accomplished? (Select any that apply) *

• None Yet
• Holds head up while on belly
• Rolls to his/her side
• Rolls from belly to back
• Rolls from Back to belly
• Sitting up but cannot lie back down
• Sitting up and can lie back down
• Crawling
• Standing but cannot sit back down
• Standing and can sit back down
• Walking

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.

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