* PLEASE FILL OUT FROM A DESK TOP RATHER THAN A MOBILE DEVICE to ensure proper submission* Name * First Name Last Name Email * Phone (###) ### #### How did you hear about Well-Rested? Your Child's Name Child's Date of Birth MM DD YYYY How many weeks gestation was your child at birth? What brings you to Well-Rested? What are your goals for working with me? What makes NOW the right time for you to be fully invested in changing your child's sleep? Please describe your family (child's siblings, general family dynamics): Please give an overview of your child's day (daycare, activities, dinner time, bedtime routine): On a scale of 1-10 what is your child's activity level? 1 - they are inseparable from the couch, and 10- I can't get this kid to slow down): 1 2 3 4 5 6 7 8 9 10 Please describe your child's amount of screen time: Are there any significant medical issues or developmental delays that I should be aware of?: If so, please elaborate. Have you noticed that your child snores or mouth breathes on a consistent basis?: yes no maybe Does your child have trouble with bed wetting? yes no sometimes Please describe your child's general sleep history: Is there anything that you have tried to improve your child's sleep? If so, please elaborate: Does your child nap? If so, please describe general timing and length: Can you tell me about your bedtime routine (start time, location, lights-out time, if you stay with them or leave the room)? Describe your home set-up (child in their own room/ shared room/ crib/ bed/ co-sleeper/ family bed). If your child sleeps or naps regularly a stroller, baby carrier, car seat, swing or on the couch, etc. please list. Describe your child's typical sleep environment (swaddle, blinds, night lights, temperature, noise, etc.): What time does your child typically wake in the morning? Does your child seem cranky, irritable, or hyperactive? If so, what time of day do you most commonly notice this behaviour? Does your child still feed at night? If so, at what time(s)?: Does your child use a soother? If so, when? Do you currently: Breastfeed Bottle feed A combination Not applicable Does your child wake at night? If so, what is the frequency? Who usually responds to your child if they wake during the night? * How does this person respond to the night wake? (i.e. stay with child, bring child into their bed, soothing methods, let child self-settle) Do you identify with any specific parenting style or philosophy? If so please elaborate: Are there any sleep approaches that do not resonate well with you? What do you think will be most difficult for you and your family in trying to achieve healthier sleep habits and in turn gain more sleep? If you are in a two parent household, do you feel that you are on the same page as your partner in terms of wanting more rest, and desire to sleep train? On a scale of 1-10, what role does consistency play in your daily life when it comes to your child (scheduling, boundaries, consequences). 1-I react very in the moment and it is inconsistent, 10- I am extremely consistent in my actions and with my words: 1 2 3 4 5 6 7 8 9 10 On a scale of 1-10 how do you feel you are coping with your child's current sleeping situation? 1- I am at my wit's end and have been unable to cope in a healthy way, 10- I am adaptable and feel it will sort itself out given more time 1 2 3 4 5 6 7 8 9 10 On a scale of 1-10 please rate the level of support that you feel you have. 1- No support, 10- Overflowing with support: 1 2 3 4 5 6 7 8 9 10 Please tell me any other information that you think may be relevant and helpful for me to know (adoption/trauma/anything out of the ordinary): Thank you! You will receive an email shortly. Whisper
