Intake Form

Parents/carer's name *

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Email *

Phone Number *

Child's Name *

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Last

Choose a Package *

Choose the package most suited to your situation. I'll be in touch shortly to book a time.

Child's Age & Birth Date *

Childs birth weight / current approx. weight

Any known allergies? Asthma? Medical issues? If so, are they on any medication?

Does your child snore, breathe with their mouth open, or sweat during their sleep?

Is your child breastfeeding / infant formula / both / none?

List your child’s feeding times, what they eat, and how much:

If breastfeeding, briefly describe the breastfeeding mother’s diet

Where does your child sleep during the day (cot, pram, carrier, car seat, etc.)

Please describe day naps (times and durations)

Where does your child sleep during the night (bassinet, cot, co-sleeping etc.)

What does your child wear to bed?

Average number of times they wake per night? Approximately how long are they awake at night and is it easy for them to go back to sleep?

Describe the room where your child sleeps at night in more detail (temperature, white noise, night light, toys, etc.)

Does your child use a dummy, cuddly toy, or any additional comforting items?

How does your child currently get put to sleep? (feeding, rocking, patting etc.)

Briefly describe your parenting style: Attachment Parent / Go with the flow / Prefer set routine?

Describe your child’s temperament: Easy / Slow to warm up / Difficult / Mixed?

Is there anything else I should be aware of or consider when making a sleep plan for your child?

What you hope to achieve while working together?

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samantha@settlesleepme.com.au