CLIENT INTAKE – OVER 12 MONTHS Name Your full name * Your partner's full name (if applicable) * Phone number * Email Address * Child's Name * Child's age & birthdate * Was your child born at term/early/late? What is your child's current weight? * Does your child snore? If so please give details * Does your child have any medical issues or allergies? * Have you ever/do you suffer from anxiety or depression? * How would you describe your child's temperament? (e.g fussy, generally happy, clingy, easy going, adaptable, up and down) * Do you believe your child is reaching age appropriate milestones? (your child health book should have descriptions of these if you are unsure) * Please describe what your child sleeps in (sleeping bag, doona, blankets, PJ's) * Does your child use a comforter or dummy? Please give details. * Describe your child's sleep environment (e.g the room is brightly lit/darkish, mobile over the cot, lots of toys/minimal toys, nightlight, air conditioned/heated to ...degrees) * Where does your child sleep for naps and night sleep (e.g. naps in lounge room in pram, naps in own room in cot, my room and bed at night/own room in cot then my bed later) * How many naps does your child usually have? Please give details of times and duration. * How do you settle your child for a nap? * What time does your child usually go to bed at night and how do you settle your child at bedtime? * How often does your child usually wake overnight and how do you settle your child back to sleep if he/she wakes? * Does your child drink milk? * Only Breast milk Only Formula Breast milk and Formula Only cow's milk Other Please give details of milk feeds over 24 hours (if applicable). * Please list approximate times over 24 hours of any solid feeds (meals and snacks). Give details of homemade meals, brands of store bought foods and approx. quantities of foods. * Do you work outside the home? If yes, which days and for how long? Who looks after your child? * Do you have other children. If yes, how many and how old are they? * Do you have any commitments outside the home (apart from work) such as school drop off/gym classes/shopping? If yes, please list times you have to leave the house and when you get back. * Do you prefer a strict schedule during the day with predictable wake up times, nap times and bedtimes or do you prefer a more flexible 'go with the flow' day? * How long can you let your child cry before you feel you have to pick him/her up? * I try and pick my child up straight away Up to 5 minutes Up to 10 minutes Up to 15 minutes Other Please describe in detail the sleep issue you are having and what you'd like to work on. * Have you tried sleep training before? If so, what did you try and what was the outcome? * Is there anything else you would like to add, that might be helpful to share? *