Sprout Sleep- Family Intake

SPROUT SLEEP SOLUTIONS

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Family Intake Form

Get Started with Sprout, tell us about your family and your needs.

We will be in touch after reviewing your form.

Parent's Names

First Name

Last Name

Parent's Names

First Name

Last Name

Email addresses

Phone Number

Country

(###)

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Name

First Name

Last Name

Child's Birthdate

YYYY

Child's age

Was your child born early?

If yes, what week were they born and what is their adjusted age?

Are there other children in the home and what are their ages?

YOUR CHILD'S MEDICAL HISTORY

Does your child have any known medical conditions or allergies that we should be aware of?

If yes, please describe

Does your child snore or mouth breathe?

YOUR FAMILY

Does your family have any specific child rearing philosophies or values?

Are there any sleep philosophies that you’ve read about and are interested in learning more about or connect with?

Is everyone in the family onboard with hiring a sleep consultant to reach your sleep goals?

Are there any sleep philosophies that you are not comfortable with?

If you’ve already tried to help your child’s sleep, please outline what you’ve tried.

YOUR CHILD'S DAY & NIGHT

What time does your child wake up in the morning?

How is their mood when they wake up?

Do they nap? If so, what time are their naps at and how long does each nap last?

What time does your child go to bed at?

How do you put your child to sleep for nap time? Please outline your nap routine.

How do you put your child to sleep at bed time? Please outline your bedtime routine.

Do they wake during the night?

If yes, please explain how you tend to them when they wake during the night? How do you put them back to sleep and who tends to them?

How many times per night are they waking and for how long are they awake?

Does your child have any night time feedings? If yes, how many and when do these take place?

Where do the night time feedings take place?

Does your child go to daycare or school? If so, please outline the drop off times and the nap/rest times. Do they sleep well there? For how long?

What is your child's temperament like? Are they happy and easy going or fussy/frustrated?

Please provide as much detail as possible.

What is your child's mood like around dinner time?

Please provide as much detail as possible.

Does your child have any screen time? If so, please share a general idea of when it is taking place during the day.

SLEEP ENVIRONMENT

Where does your child currently sleep?

ie. Their bedroom, bassinet in parents room, car, stroller, shared bedroom, family bed etc.

For naps:

At night:

Do you know the temperature of your child's bedroom? How do you monitor this?

On a scale from 1-10, how dark is your child's bedroom? 1 being bright and sunny and 10 being dark and cave like. Do you have black out blinds or curtains?

Does your child use a pacifier, stuffed animal or lovey at bedtime?

SLEEP GOALS

What are your family's sleep goals?

Is your family fully able to commit to reaching these goals right now and for at least the next few weeks?

ie. no travel coming up or other big changes

Please share any additional information that you'd like us to know.

Would you like to share your child’s doctors contact information for us to provide a copy of our process and results for your child’s records? Is so, please provide their name and phone number.

How did you hear about Sprout Sleep Solutions?

Thank you for choosing Sprout. We look forward to working with your family.