Intake Form | Smart Night Sleep

Client Intake Form

Parent 1 First Name

Parent 2 First Name

Parent 1 Last Name

Parent 2 Last Name

Phone

Address

Your Child's Name

Due Date

Birthdate

How Old Is Your Child

Briefly describe the labor and delivery of your child

Does your child have any medical issues? Please describe.

Does your child consistently snore or mouth breathe while sleeping?

Does your child have any siblings? Names? Ages?

Does your child use any sort of comfort item? (lovey, pacifier, etc...)

Does you child have any sleep associations? Sound machines, rocking to sleep, etc...

Is your child swaddled?

Is your child teething?

Describe your child's current sleeping arrangements.

Is your baby breast fed or bottle fed? Please note if they are weaned.

Who takes primary care of your child during the day?

Do you have any feeding issues that you would like to share?

What is your child's current feeding schedule?

What is your child's current sleep schedule?

How many naps does your child take per day? How long are those naps?

Please share a bit about your child's personality.

Briefly describe your parenting philosophy? How do you feel about cry it out? Is there anything you would like us to know?

Please explain your sleep issues. Are there any night wakings, problems getting to bed, waking too early, short naps?

What is your child's usual bedtime?

How does your child fall asleep?

What have to tried in the past to get your child to sleep?

What is your overall goal for your child's sleep? What are your expectations for Smart Night Sleep?

Are there any questions or concerns that you would like us to know?

Did you have an introductory call?

Please let us know who we can thank for sending you our way or how else you found us:

I agree to the Client Agreement.View Client Agreement

I/We understand the need for us, the parents or caregivers, to continue to use the plan and program firmly and consistently after the training is completed in order to ensure the success of the sleep training program. We understand that our failure to do so will jeopardize the continued success of the program and our child(ren)'s ability to continue with the healthy sleep habits instilled by the program. The first few weeks of formally sleep training the child[ren] are vital to the success of the program. One hundred percent consistency is required until the child’s sleep habits improve after which time, we are able to vary from the plan with 80% of the time consistent and with 20% of the time of inconsistent.

Your Signature

Thank you! Looking forward to speaking soon!

Client Intake Form

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