Family Questionnaire

Thank-you for choosing Good Night Sleep Site as your sleep consultant and support. Please fill out the below questionnaire in its entirety. If the section does not apply to your situation please fill it in with n/a. Having this information will be useful in creating the right Sleep Plan for you and your child.

We look forward to starting your sleep journey with you!

Talk soon!

Good Night Sleep Site

Parent Full Name *

Parent Full Name

Child's Full Name *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Email *

Phone Number *

Cell Phone

How did you hear about Good Night Sleep Site?

Were you referred to a particular Sleep Consultant? *

Did you attend a seminar? *

Have you seen our advertisement in a magazine *

Have you seen or heard our advertisement on TV or Radio? *

Have you seen our advertisement on the Internet/Search Engine? *

Getting to know your child

How old is your baby/toddler? *

What is your child's birthdate? *

What was your expected delivery date? *

How much do they currently weigh? *

Please briefly describe your labour & delivery with your child *

Does your child have any medical issues? *

Does your child consistently snore or mouth breath while sleeping? *

Does your child have any siblings? *

Does your child use a pacifier, lovey, or any other comfort item?

Is your baby/toddler swaddled? *

Is your baby teething? *

If you have twins - do they share a room and/or bed?

Feedings

Is your baby breast fed or bottle fed? *

Breast
Bottle
Both
N/A

Who takes primary care of your child during the day? *

Do you have any feeding issues that you would like to share? *

What is your baby's current feeding schedule? *

Please list feeding times as well

Personality, Temperament, and Philosophy

Please share with us your baby's or toddlers personality and temperment *

Briefly describe your parenting philosophy. How do you feel about cry it out? Is there anything that you would like us to know or keep in mind? *

Sleep History and Current Schedule

How many naps does your baby/toddler take per day and how long is each nap? *

Where does your baby/toddler sleep during the day and at night? *

Does your baby/toddler use any sleep associations? Sound machines, mobiles, crib aquariums, pacifiers, etc. *

Please explain your sleep issues with us. Are there night wakings, problems getting to bed, waking too early, not taking naps, etc. *

What time is your child's usual bedtime?

How does your child fall asleep? Nursing/bottle, bed time routine, put down awake/asleep, etc. *

What is your child's current sleep routine and schedule starting from wake-up in the morning until bedtime. Please list times and include as much information as possible - number of night wakings, etc. *

What have you tried in the past to get your baby/toddler to sleep? How have you handled night wakings, crying at bed times etc... Have you tried other methods of sleep training and how did your baby/toddler react to it? *

Goals and Expectations

What is your overall goal for your child's sleep? What are your expectations with Good Night Sleep Siite? Please explain your response in full. *

Please list any questions, concerns or information that you would like us to know. *

Who is your pediatrician/family doctor?

Do you think they would benefit from information about Good Night Sleep Site? If so please list for us their mailing address information.

Did you have a 15-minute Complimentary Consultation with Good Night Sleep Site?

Comment

Thank-you! We will be emailing you your Letter of Agreement and our first available time to book your 60-minute consultation within 24-hours of receiving your completed questionnaire. Please note – If you haven’t heard back from us within 24-hours please check your junk mail folder as occasionally our emails can end up in there.