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Home
About
Go To Sleep
Menu Toggle
The Ultimate Sleep Plan Package
DIY Personalized Sleep Plan
MOM-bership
Digital Downloads
Testimonials
Blog
Contact
Consulting Intake Form
Name
(Required)
First
Last
Phone Number
(Required)
Email
(Required)
example@example.com
How did you hear about us?
(Required)
Instagram
Facebook
Friend/Family
Online
Other
Name and age of your child
(Required)
My main issues with my child's sleep are...
(Required)
My main goals for my child's sleep are...
(Required)
What best describes your feelings on crying?
(Required)
I can handle some crying.
I have a really hard time whenever my baby cries.
Have you tried any sleep methods before contacting me? If yes, which were they and have they helped at all? Did you experience any negative effects from these methods?
(Required)
Milestones your child has reached are...
(Required)
Holding head up when on their tummy
Rolling from back to belly
Rolling from belly to back
Sitting up assisted
Sitting up unassisted
Crawling
Walking with assistance
Walking without assistance
Standing up and CAN sit back down on their own
Standing up but CANNOT sit back down on their own
What does your daily routine look like from the moment you child wakes up for the day to the moment they fall asleep?
(Required)
What is your child's bedtime routine, if any? On average, from start to finish, how long does your bedtime routine usually take?
(Required)
Does your child use a pacifier?
(Required)
Yes, cries when it falls out during the night and needs it to be replaced for them.
Yes, does not cry when it falls out during the night / can independently replace it.
No pacifier.
Does your child use any of the following sleep props to help them fall asleep? Choose all that apply.
(Required)
Bottle to sleep
Rock to sleep
Nursing to sleep
Bouncing/swaying/any movement to help them fall asleep
Rub back/belly till they fall asleep
Do you use white noise during naps/bedtime?
(Required)
Yes
No
Not all the time
If you use a white noise machine, is it bluetooth?
(Required)
Yes, it is Bluetooth-controlled (like Hatch).
No
My baby is currently...
(Required)
Breastfeeding
Bottle feeding (formula, combo, or breastmilk)
Combo of breast and bottle
Starting solids
Solids only
Is your child's sleeping space blacked out for sleep?
(Required)
Yes, I use black out curtains/shades.
Kind of, still some light comes in.
No, I use plain blinds/curtains.
Does your child use a sleep sack for naps/bedtime?
(Required)
Yes
No
Not all the time
What brand of sleep sack/swaddle to you currently use?
(Required)
What does your child wear to bed?
(Required)
What is in your child's crib when they are sleep?
(Required)
How many hours does your child sleep overnight?
(Required)
My child is...
(Required)
Strong willed.
Has a hard time with change.
Flexible/easily adjusts to change.
Clingy/experiences seperation anxiety.
Cranky/fussy.
Happy, playful. Usually in good spirits.
How many hours does your baby sleep during the day (naps)?
(Required)
In detail, please describe what sleep problems you are experiencing.
(Required)
What difference(s) would you like to see in sleep by the end of our time together?
(Required)
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