Assessment Form
Please be as detailed as possible. This will give me a good look at what is going on and how to help you reach your sleep goals.
Parent Name (s)
Your answer
Email
Your answer
Phone Number
Your answer
Address (If you are interested in an In-Home Consultation)
Your answer
Who are we helping today?
Name of child, age and birthday:
Your answer
How close to your due date was your baby born? Were there any complication?
Your answer
What is the sleep goal for your family and is everyone in agreement with this goal?
Your answer
A little history about your child's sleep habits from birth on.
Your answer
Does your child have any medical issues we should be aware of?
Your answer
Please describe your child’s sleep environment.
For Example: Crib, swing, car, how dark, use of pacifier, room temp, etc.
Your answer
What time does he/she get up for the day?
Your answer
Describe naps.
How many naps per day? How long is each of these naps in general? What times do these naps take place (clock time)?
Your answer
Describe bedtime.
What time is bedtime? Do you have a bedtime routine?
Your answer
Night Feedings
How many does he/she need? How long does it take to get your child back to sleep after these feedings?

Your answer
Night Wakings
Does your child wake up at other times other than for feedings? If yes, what do you do to get him/her back sleeping and how long does it take?
Your answer
Is your child in daycare or have a nanny during the day?
If yes, how do they get your child down to a nap?
Your answer
Does your child snore or mouth breathe?
Your answer
Would you be willing to share your pediatrician’s name and location/medical group with me?
I would love to send him/her a report for your child’s file documenting the process that we went through and the results.
Your answer
Where did you learn about me?
Your answer
I look forward to working with your family and helping everyone get a better night’s rest. Thank you for providing me with the above information. I will contact you shortly to discuss our next steps.
Best, Danielle
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