CLIENT INTAKE - UP TO 12 MONTHS

Do you swaddle your baby? If so, how? (arms up/down, tightly/loosely, specific type of swaddle)

What does your baby sleep in? (sleeping bag, blankets etc). Please also list the brand of any products you use if applicable.

In what position does your baby usually sleep?

Back

Front

Side with Wedge

Other

In which room does your baby usually sleep for day naps?

In which room does your baby usually sleep at night time?

Please describe your baby's sleep environment at night (light/dark, noise, fan, air- conditioning/heating, sleeps with other family members?).

Does your baby use a dummy and/or cuddly. If so, when? (just at night, only in the car, for all sleeps, when awake and cranky)

What does your baby drink?

Only Breast milk

Only Formula

Breast milk and Formula

If formula fed, please specify volumes and approximate times of feeds.

If breast fed, please indicate approximate feed times day and night.

If your child eats solid foods: please indicate how many meals, approximate times of meals and examples of types and amounts of foods usually eaten.

Please describe your baby's development. In your opinion, is he or she reaching age appropriate milestones? (smiling, reaching, laughing, lifting head etc) Your child health record book should have descriptions of these if you are unsure.

Describe your child's temperament (easy going, generally happy, fussy, generally grumpy etc).

Does your baby have any medical conditions or current health concerns? If so, have you consulted with a health professional?

How does your child usually wake in the morning? (crying, babbling, talking, playing etc)

How do you usually settle your baby for sleep? (rocking, patting, breast feeding until asleep etc) and for how long?

Please describe a typical day from wakeup in the morning to bedtime at night. Include nap times/lengths, activities, feeding and any other routine or major part of your baby's day.

Please describe a typical night from bedtime at night to wakeup in the morning.

Please list any regular commitments you may have that require you to be out of the house at certain times (school run, shopping, work etc).

Please describe your parenting style. Do you prefer a more relaxed parenting style or do you prefer routine?

What would you like to work on regarding your child's sleep? Please be as specific as you can.

Have you ever tried any kind of sleep training before? Please give details.

On a scale of 1-5, how would you describe your need to pick your baby up when he/she cries? 1 - I can put up with my baby crying for more than 20 minutes. 5 - I can't I stand my baby crying for even a minute. I just have to pick my baby up and comfort him/her.

1

Please note anything else not already covered, you think might be relevant to discuss..

CLIENT INTAKE – UP TO 12 MONTHS

MEET TORI

JUMP T0

SLEEP PROGRAMS