Parent's Name(s) (required)

    Consultant's Name (required)

    Cell Phone (required)

    Alternate Phone

    Email (required)

    Street Address (required)

    City (required)

    State (required)

    Zip Code (required)

    What is the biggest challenge for your family in regard to sleep?

    What are your sleep goals for your family?

    Name of Child

    Estimated Due Date

    Actual Delivery Date

    Does your child have any significant medical history? (ex. reflux, colic, allergies, surgeries, special needs, etc.)
    yesno

    If yes, please explain:

    Does your child mouth breath or snore?
    yesno

    My child typically takes naps or sleeps at night in: (check all that apply)
    CribFamily bedToddler bedWhile being heldSwing/bouncerCar seatInfant CarrierStroller

    Rate the darkness of your child's regular sleep environment during the day and night?
    Day sleep
    Bright lightSomewhat lightSomewhat darkPitch black

    Night sleep
    Bright lightSomewhat lightSomewhat darkPitch black

    Rate the noise level of your child's sleep environment?
    Day sleep
    SilentVery occasional subtle noiseOccasional noiseLoud and noisy

    Night sleep
    SilentVery occasional subtle noiseOccasional noiseLoud and noisy

    I use the following to help my child sleep: (check all that apply)
    RockingPattingShushingNursing/bottleBeing heldWhite noiseLovey toyPacifierSwaddlingWalking/movingCar/Stroller rideTVMusicOther

    If Other

    When I put my child to sleep he/she is:

    My child wakes for the day around?

    When my child wakes up he/she is:

    How many naps a day does your child typically take?
    12345none

    Do you currently have your child on a set schedule for naps and bedtime?
    yesno

    What time does your child take nap 1, 2, 3, etc and how long is each nap usually?

    How would you describe the overall mood of your child? Happy, cranky, laid back?

    Is your child in daycare, if yes, please explain schedule? Drop off, naps, pick up?

    My child usually goes to bed around?

    Our normal bedtime routine is?

    If your child wakes at night, how many times and how do you respond?

    Who typically handles night waking?

    Does your child nurse or bottle feed
    yesno
    If yes, how many feedings and at what time?

    What developmental milestones (if any) has your baby accomplished? Check all that apply
    Rolling from belly to backRolling from back to bellySitting upBut can't lay back downCrawlingStanding in Crib

    Any other information you would like to share?

    I have read and understand the Healthy Care Practitioner and Liability/Disclaimer (required)


      First Name (required)

      Last Name (required)

      Email (required)

      Message


        Consultant Name(s) (required)

        Parent's Name(s) (required)

        Cell Phone (required)

        Alternate Phone

        Email (required)

        Street Address (required)

        City (required)

        State (required)

        Zip Code (required)

        What is the biggest challenge for your family in regard to sleep?

        What are your sleep goals for your family?

        Name of Child

        Estimated Due Date

        Actual Delivery Date

        Does your child have any significant medical history? (ex. reflux, colic, allergies, surgeries, special needs, etc.)
        yesno

        If yes, please explain:

        Does your child mouth breath or snore?
        yesno

        My child typically takes naps or sleeps at night in: (check all that apply)
        CribFamily bedToddler bedWhile being heldSwing/bouncerCar seatInfant CarrierStroller

        Rate the darkness of your child's regular sleep environment during the day and night?
        Day sleep
        Bright lightSomewhat lightSomewhat darkPitch black

        Night sleep
        Bright lightSomewhat lightSomewhat darkPitch black

        Rate the noise level of your child's sleep environment?
        Day sleep
        SilentVery occasional subtle noiseOccasional noiseLoud and noisy

        Night sleep
        SilentVery occasional subtle noiseOccasional noiseLoud and noisy

        I use the following to help my child sleep: (check all that apply)
        RockingPattingShushingNursing/bottleBeing heldWhite noiseLovey toyPacifierSwaddlingWalking/movingCar/Stroller rideTVMusicOther

        If Other

        When I put my child to sleep he/she is:

        My child wakes for the day around?

        When my child wakes up he/she is:

        How many naps a day does your child typically take?
        12345none

        Do you currently have your child on a set schedule for naps and bedtime?
        yesno

        What time does your child take nap 1, 2, 3, etc and how long is each nap usually?

        How would you describe the overall mood of your child? Happy, cranky, laid back?

        Is your child in daycare, if yes, please explain schedule? Drop off, naps, pick up?

        My child usually goes to bed around?

        Our normal bedtime routine is?

        If your child wakes at night, how many times and how do you respond?

        Who typically handles night waking?

        Does your child nurse or bottle feed
        yesno
        If yes, how many feedings and at what time?

        What developmental milestones (if any) has your baby accomplished? Check all that apply
        Rolling from belly to backRolling from back to bellySitting upBut can't lay back downCrawlingStanding in Crib

        Any other information you would like to share?

        I have read and understand the Healthy Care Practitioner and Liability/Disclaimer (required)


          Parent's Name(s) (required)

          Cell Phone (required)

          Alternate Phone

          Email (required)

          Street Address (required)

          City (required)

          State (required)

          Zip Code (required)

          What is the biggest challenge for your family in regard to sleep?

          What are your sleep goals for your family?

          Name of Child

          Estimated Due Date

          Actual Delivery Date

          Does your child have any significant medical history? (ex. reflux, colic, allergies, surgeries, special needs, etc.)
          yesno

          If yes, please explain:

          Does your child mouth breath or snore?
          yesno

          My child typically takes naps or sleeps at night in: (check all that apply)
          CribFamily bedToddler bedWhile being heldSwing/bouncerCar seatInfant CarrierStroller

          Rate the darkness of your child's regular sleep environment during the day and night?
          Day sleep
          Bright lightSomewhat lightSomewhat darkPitch black

          Night sleep
          Bright lightSomewhat lightSomewhat darkPitch black

          Rate the noise level of your child's sleep environment?
          Day sleep
          SilentVery occasional subtle noiseOccasional noiseLoud and noisy

          Night sleep
          SilentVery occasional subtle noiseOccasional noiseLoud and noisy

          I use the following to help my child sleep: (check all that apply)
          RockingPattingShushingNursing/bottleBeing heldWhite noiseLovey toyPacifierSwaddlingWalking/movingCar/Stroller rideTVMusicOther

          If Other

          When I put my child to sleep he/she is:

          My child wakes for the day around?

          When my child wakes up he/she is:

          How many naps a day does your child typically take?
          12345none

          Do you currently have your child on a set schedule for naps and bedtime?
          yesno

          What time does your child take nap 1, 2, 3, etc and how long is each nap usually?

          How would you describe the overall mood of your child? Happy, cranky, laid back?

          Is your child in daycare, if yes, please explain schedule? Drop off, naps, pick up?

          My child usually goes to bed around?

          Our normal bedtime routine is?

          If your child wakes at night, how many times and how do you respond?

          Who typically handles night waking?

          Does your child nurse or bottle feed
          yesno
          If yes, how many feedings and at what time?

          What developmental milestones (if any) has your baby accomplished? Check all that apply
          Rolling from belly to backRolling from back to bellySitting upBut can't lay back downCrawlingStanding in Crib

          Any other information you would like to share?

          I have read and understand the Healthy Care Practitioner and Liability/Disclaimer (required)


            Parent's Name(s) (required)

            Cell Phone (required)

            Alternate Phone

            Email (required)

            Street Address (required)

            City (required)

            State (required)

            Zip Code (required)

            What is the biggest challenge for your family in regard to sleep?

            What are your sleep goals for your family?

            Name of Child

            Estimated Due Date

            Actual Delivery Date

            Does your child have any significant medical history? (ex. reflux, colic, allergies, surgeries, special needs, etc.)
            yesno

            If yes, please explain:

            Does your child mouth breath or snore?
            yesno

            My child typically takes naps or sleeps at night in: (check all that apply)
            CribFamily bedToddler bedWhile being heldSwing/bouncerCar seatInfant CarrierStroller

            Rate the darkness of your child's regular sleep environment during the day and night?
            Day sleep
            Bright lightSomewhat lightSomewhat darkPitch black

            Night sleep
            Bright lightSomewhat lightSomewhat darkPitch black

            Rate the noise level of your child's sleep environment?
            Day sleep
            SilentVery occasional subtle noiseOccasional noiseLoud and noisy

            Night sleep
            SilentVery occasional subtle noiseOccasional noiseLoud and noisy

            I use the following to help my child sleep: (check all that apply)
            RockingPattingShushingNursing/bottleBeing heldWhite noiseLovey toyPacifierSwaddlingWalking/movingCar/Stroller rideTVMusicOther

            If Other

            When I put my child to sleep he/she is:

            My child wakes for the day around?

            When my child wakes up he/she is:

            How many naps a day does your child typically take?
            12345none

            Do you currently have your child on a set schedule for naps and bedtime?
            yesno

            What time does your child take nap 1, 2, 3, etc and how long is each nap usually?

            How would you describe the overall mood of your child? Happy, cranky, laid back?

            Is your child in daycare, if yes, please explain schedule? Drop off, naps, pick up?

            My child usually goes to bed around?

            Our normal bedtime routine is?

            If your child wakes at night, how many times and how do you respond?

            Who typically handles night waking?

            Does your child nurse or bottle feed
            yesno
            If yes, how many feedings and at what time?

            What developmental milestones (if any) has your baby accomplished? Check all that apply
            Rolling from belly to backRolling from back to bellySitting upBut can't lay back downCrawlingStanding in Crib

            Any other information you would like to share?

            I have read and understand the Healthy Care Practitioner and Liability/Disclaimer (required)


              Parent's Name(s) (required)

              Cell Phone (required)

              Alternate Phone

              Email (required)

              Street Address (required)

              City (required)

              State (required)

              Zip Code (required)

              What is the biggest challenge for your family in regard to sleep?

              What are your sleep goals for your family?

              Name of Child

              Estimated Due Date

              Actual Delivery Date

              Does your child have any significant medical history? (ex. reflux, colic, allergies, surgeries, special needs, etc.)
              yesno

              If yes, please explain:

              Does your child mouth breath or snore?
              yesno

              My child typically takes naps or sleeps at night in: (check all that apply)
              CribFamily bedToddler bedWhile being heldSwing/bouncerCar seatInfant CarrierStroller

              Rate the darkness of your child's regular sleep environment during the day and night?
              Day sleep
              Bright lightSomewhat lightSomewhat darkPitch black

              Night sleep
              Bright lightSomewhat lightSomewhat darkPitch black

              Rate the noise level of your child's sleep environment?
              Day sleep
              SilentVery occasional subtle noiseOccasional noiseLoud and noisy

              Night sleep
              SilentVery occasional subtle noiseOccasional noiseLoud and noisy

              I use the following to help my child sleep: (check all that apply)
              RockingPattingShushingNursing/bottleBeing heldWhite noiseLovey toyPacifierSwaddlingWalking/movingCar/Stroller rideTVMusicOther

              If Other

              When I put my child to sleep he/she is:

              My child wakes for the day around?

              When my child wakes up he/she is:

              How many naps a day does your child typically take?
              12345none

              Do you currently have your child on a set schedule for naps and bedtime?
              yesno

              What time does your child take nap 1, 2, 3, etc and how long is each nap usually?

              How would you describe the overall mood of your child? Happy, cranky, laid back?

              Is your child in daycare, if yes, please explain schedule? Drop off, naps, pick up?

              My child usually goes to bed around?

              Our normal bedtime routine is?

              If your child wakes at night, how many times and how do you respond?

              Who typically handles night waking?

              Does your child nurse or bottle feed
              yesno
              If yes, how many feedings and at what time?

              What developmental milestones (if any) has your baby accomplished? Check all that apply
              Rolling from belly to backRolling from back to bellySitting upBut can't lay back downCrawlingStanding in Crib

              Any other information you would like to share?

              I have read and understand the Healthy Care Practitioner and Liability/Disclaimer (required)