Questionnaire

 

 

 

Thank-you for choosing Good Night Sleep Site as your sleep guide 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 choosing the right method and building the right Sleep Plan for you and your child.

Mother's Full Name:

Father's Full Name:

Child's Full Name:

Street Address:

City:

State / Province / Region:

Postal / Zip Code:

Country:

Email:

Home Phone:

Mobile Phone:

How did you hear about Good Night Sleep Site?

Where you referred to a particular Sleep Consultant?:
YesNo
If so, please list her name:

Did you attend a seminar?
YesNo
If so, who was the speaker?

Which city was the seminar held?

Have you seen our advertisement in:
1. A Magazine?
YesNo
In what publication and/or city?

2. TV/Radio Show?
YesNo
In what city?

3. Website/Search Engine?
YesNo
Please list which one?

Or did you hear about us via?
NewsletterGNSS Facebook PageOther Facebook PageFamily or FriendPinterestTwitterYouTubeOther

If other, please list.

Getting to know your child

How old is your baby / toddler?

What is your child's birthdate? (Year/Month/Day) format

What was your EDD Expected Delivery Date?

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 ?
YesNo

Does your child have any siblings?

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

Is your baby/toddler swaddled?
YesNo

Is your baby teething?

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

Feedings

Is your baby breast fed or bottle fed?
Breast FedBottle FedBothNeither

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

What is your baby's current feeding schedule?
*Please list times as well

Personality, Temperament, and Philosophy

Please share with us your baby's or toddlers personality and temperament.

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 Site? Please explain your responses 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?
YesNo

Which Sleep Consultant did you speak with?
Alanna McGinnJamie ContariniTara O’MahonyAmanda PascoeLiane MamoJulia WalshErin OliveiraKristina AmerikanerLaura ArmstrongSarah DiCenzo

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.

We look forward to starting your sleep journey with you!

Talk soon!

Good Night Sleep Site