Sleep Assessment Questionnaire – Embracing Parenthood

Thank-you for your interest in Embracing Parenthood Sleep Support Package.

I look forward to supporting you and your family. Please could I ask that you complete and submit this form. Once complete I will then forward an invoice relating to your chosen sleep package. We can then agree a time and date to work through your plan. Should you have any questions please do not hesitate to ask. Really looking forward to getting to know you, Melissa – Embracing Parenthood

Email

You Name

First

Last

Child's Name

First

Last

Child's Date of Birth:

Address: (Only required for home visits)

What support package are you interested in?

New Born Settled Sleep Package
Put to bed package, with personal sleep plan and 2 weeks aftercare via Whatsapp or email
Personal Sleep Plan- personal sleep plan with 10 days aftercare via Whatsapp or email.
Free Discovery Call

Does your child have any allergies or medical diagnosis?

Does your child currently avail of a nap schedule? If so, describe it here:

What does your child's bedtime routine look like? Include who puts them to bed, and how they fall asleep. E.g. Bath, Play, Story, Breastfed to sleep by mum and transferred into cot

What does your child's sleeping environment look like? E.g. Baby sleeps in their own cot in the nursery. Or Baby co-sleeps with parents on mums side of the bed. The room has blackout blinds and we use white noise

Does your child use a dummy?

Yes and I often have to reinsert it
Yes, but if it falls out they do not need it reinserted
No

Does your child use any of the following to fall asleep, either during the day or night?

Which developmental milestones (if any) has your child accomplished? Select all that apply. (This will give you an idea as to whether you need to support them with laying down or whether swaddle needs removed)

Does your child experience any of the following symptoms. Please tick all that apply.

Which statement best describes how you feel about crying:

I do not mind hearing some crying, as long as I respond within a short timeframe
Crying makes me feel anxious. I wouldn’t feel comfortable leaving the room
Other

Which of these activities apply to your child? If your child is under 18 months skip this question.

How does your child respond when you leave the room? If your child is under 6 months skip this question).

My child remains calm when I leave the room
Sometimes my child remains calm and sometimes they get very upset
My child becomes very upset then I leave the room

What do you hope to achieve by using this service?

Describe what has been happening with your child's sleep to date:

How did you hear about Embracing Parenthood:

MEDICAL DISCLAIMER: The recommendations provided during this consultation is not a subsititute for medical advice. The advice is intended for use with children without diagnosed medical conditions or diagnosed symptoms. Always seek advise from a medical professional regarding any concerns about your child's health. It is recommended to obtain your Doctors permission before using any of the behavioural strategies provided. LEGAL NOTICE: In no event will Embracing Parenthood be liable to you for any claims, losses, injury or damages as a result of reliance on the information provided. Embracing Parenthood does not accept responsibility for errors, omissions, or contrary interpretation. Using this plan is solely at your own risk. REFUND POLICY: Payment is required to secure the booking. Refunds are not possible after payment has been made. This is due to me commencing the tailored sleep plan. COPYRIGHT NOTICE: The information provided is subject to Copyright Law. It must not be shared reproduced without permission from the author.