CLIENT INTAKE QUESTIONNAIRE

In order for WeeSleep to get a better understanding of the sleep issues your little one is having, it is important you answer a few questions about your child's sleep habits prior to our consultation.

Please answer the below questions in the spaces provided and send the completed form to your consultant 48 hours before your scheduled consultation.

Parent's Name



Child's Name



Birthday



Mailing Address
Street



City



Zip Code / Postal Code



Country



Email Address



Phone Number



1. What grade is your child in?



2. How much does (s)he weigh in lbs.?



3. What is the gender of your child?

malefemale


4. Does your child take any medication?

yesnot sureno

If yes, what?



5. Have there been any health issues or concerns?

yesno

If yes, please describe



6. Have you spoken to your doctor about your child's sleep difficulties?

yesno


7. What time does your child wake to start the day?



8. What time is your child's bedtime?



9. Do you have a bedtime ritual or routines with your child?



10. Please explain in detail what kind of issues you are having with your child.


11. How long have you had these issues and have you tried to resolve them previously? Please explain.



12. Is there anything else you'd like to share before we meet?



Who may I thank for referring you?