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Sleep through the night. Again.
Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
Child's Name
Child's Age
Child's Gender
Male
Female
Child's Current Weight; Birth Weight; Born Prematurely?
What was your expected due date? Actual due date?
Parents
Parents, are you:
Single
Married
Divorced
Co-parenting
Are you both currently working? If so, what hours?
Do you have a nanny/caregiver? If so how many hours/week?
What's a typical day like for you? Do you take time to yourself(ves)? What activities are you involved in after work?
How is your relationship since birth? Do you find it easy to communicate?
How would you describe the overall energy of the household? Check all that apply.
Happy
Laid-back
Busy
Stressful
Chaotic
Overwhelming
Describe your parenting style (if any) i.e. Parent-led, Child-led, Attachment, etc. Have you recently begun a new style of child-rearing due to difficulties with a previous one?
Has your daily routine changed recently? If so, please briefly describe. (New home, new sibling, daycare, etc).
Mother
On a scale of 1-10 rate your current overall health?
Describe how you’ve been bonding with your baby?
How are you sleeping? How is your appetite?
Do you plan on breastfeeding? If so how long do you plan to?
Do you often feel anxious or stressed, or have upsetting thoughts you can’t seem to get out of your mind? Have you experienced PPD in the past? If so, briefly explain.
Child
Medical Well-Being: How is the child’s general health, any existing medical conditions or has the child been sick a lot?
When was your child's last pediatrician visit?
MM
DD
YYYY
Did your pediatrician have any concerns about your child's health and/or development?
Has your child ever been diagnosed with reflex, silent reflux, GERD, or sleep apnea by a doctor?
Is child currently taking any medications?
How long ago did child's sleep issue become a problem for your family?
On average, what time does your child wake up and go to bed at night? How long does it take them to fall asleep?
Do you currently have a morning, naptime and/or bedtime routine? If so, briefly describe:
Do you currently have child on a schedule? Is there anything to consider that disrupts consistent scheduling i.e. second sibling, driving to daycare, travel, church, etc?
What does a typical day look like from 7am to bedtime? How many hours of sleep is your child getting during this time?
What does a typical night look like from bedtime to 7am? How many (if any) times a night is baby waking with protest? Average hours of total sleep?
How does baby fall asleep? Check all that apply.
While feeding
Being rocked
Being held
In crib alone
In bed with parent
In bed alone
In crib/co-sleeper in parent's room
With pacifier
Is your child currently using a pacifier? If so, how often? ( i.e. just for naps, in carseat etc.)
Does your child snore regularly?
Yes
No
Does your child spit up often, or vomit during the day? Acts hungry but only takes small meals or cries during/after a feeding
Where does your child sleep for naps and at night? Do they share a room with a sibling? i.e. crib, stroller, swing, nursery, parent’s room etc.
Is child currently going to daycare or another outside care organization?
Has the child been away from home more than usual, for travel or family vacation?
Is your child doing any new activities, and if so, are they age/temperament appropriate?
Has your child been teething or getting over an illness or recent accident?
Is there anything else going on in your home that you think might be affecting your child’s sleep? (Environment, family relationships, new sibling, job change, a move, illness/death in the family)
Feeding + Sleep Habits
Is your child fed by breast milk, formula or supplementing both?
How many times per day does your child get milk, and if by bottle, how many ounces per bottle?
Is your child eating solids, how often and how much per day?
Has your child’s diet changed recently? If so, briefly explain.
Development: Any new motor skills? Are they hitting milestones at appropriate times?
Do you consider your child’s sleep issue:
A very serious problem
A small problem
No problem at all for them - I'm just tired!
Have you tried any sleep training methods in the past? Please explain the experience.
How do you feel about allowing your child to cry?
Making any sorts of changes to a child’s current conditions and routine can cause a bit of upset. How long would you be comfortable with your child’s protest when adjusting to their new routine?
Have you read any sleep books or articles from sleep experts (such as Ferber, Kim West, Babywise etc?)
Is there a method you like? Is there a particular method you are NOT willing to work with?
In a perfect world, how & where would your child sleep for naps/night?
What are your overall goals for working with SATC? Check all that apply.
Child Sleep 5+ hours at night
Baby sleeping until at least 6am
Nighttime weaning
Bottle weaning
Develop nap schedules
Nap lengthening
Develop nap & nighttime routine
Room/Crib Transitioning
Pacifier weaning
Develop self-soothe ability
Dealing with fears (night terrors/mares)
Reduce frequent waking at night
Age-appropriate schedules
Keeping child in their own room all night
Thank you!
