SLEEP LEARNING INTAKE QUESTIONNAIRE

Name

First Name

Last Name

Phone

(###)

###

####

Email Address

Is your child at least 4 months and 14lbs ?

Is your child currently in a developmental leap, sick, teething, or adjusting to a time difference?

Does your child have any medical issues I should know about?

What is your child's bedtime?

Where is your child sleeping? (In his/her room, your room, in a crib, bassinet, pack n play, co-sleeping, etc.?)

Does your child still feed at night? Is so, how many times? how many ounces per feed? and what times?

What time is your child waking for the day?

How many times per day is He/She napping? For how long? and where?

How do you currently try to get your child to sleep?

How do you respond when He/She wakes?