Infant, Child & Family Sleep Consultant Port Alberni, BC
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Consultation Form
Clear some time when you will not be interrupted, and where you have the time to focus on thoughtfully completing this form. It will take most people about 1 hour to complete. For some it could take longer. I totally get that this request sounds both overwhelming, and a bit insane given how sleep deprived you are!! But the more information you can provide me now, the more time we will have for actual problem solving, and planning later!! Take your time, sit, reflect, and ponder. It may help to do something to relaxing such as drinking some delicious tea (or wine!), or putting on your favourite tunes. Trust me, its worth it 🙂
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Your Name
*
First
Last
Partner's Name
First
Last
Children's Name(s), Age(s) and Birthdate(s)
*
Example: John Smith (January 23, 2018)
Address
Phone Number
*
(XXX) XXX-XXXX
Email
*
How do you currently get your child to fall sleep? Is this the same for both naps and nighttime?
Does your child use a pacifier/soother/dummy?
Do you have a bedtime routine? If yes, what do you do?
Where does your child sleep? (i.e. your bed, crib, cot, toddler bed etc.)
Have you, or do you, ever share a sleep space with your child? (No judgments here!)
Yes
No
Sometimes
Do you have any concerns about co-sleeping, bed sharing, or sleeping close to your child?
Please describe your successes thus far with sleep
Describe your challenges with regards to daytime sleep (i.e. naps)
*
Please describe your challenges with settling to sleep at bedtime
Describe the over-night period, from bedtime to waking up for the day
Please share what issues (if any) have arisen out of these challenges. Please consider how your child's sleep habits have effected you, your child, and the rest of your family
Describe your child's day time behavior?
What have you tried so far? What helped? Did anything make sleep worse?
Please detail what your goals are regarding your child's sleep
Describe a typical "day in the life" for you and your child
Do you have any significant health concerns regarding your child?
Has your child suffered from any of the following conditions?
Colic
Extreme Gas
Food Insensitivity / Intolerance
Allergy
Gastroesophogeal Reflux (GERD)
Traumatic Birth
Prematurity
Prolonged Hospitalization
Prolonged Separation from Mother
Other (please specify below)
Is your child taking any prescribed, over-the-counter, herbal or naturopathic medicines?
Is your child taking any vitamins or mineral supplements?
Is your child currently seeing any other health care professional, or alternative/complementary therapist? (if yes, please specify)
Does your child receive breast-milk?
Yes
No
Please share your child's typical diet in an average week. Include approximate feed/meal times.
Is your child generally a good feeder/eater?
Yes
No
Varies
Are there any concerns regarding your child's weight?
Please share your own diet in an average week
How many cups of coffee, tea, or caffeinated beverages do you consume on an average day?
How many servings of alcohol do you consume in an average week?
Note: a serving of alcohol includes 12oz of beer/cider, or 5oz of wine, or 1.5oz of spirit
Briefly share your child's 'Birth Story.' Include duration, complications, trauma, and impressions, if any.
Have you (or your partner) ever suffered from any of the following conditions?
Post Traumatic Stress
Depression
Anxiety
Recent Illness or Infection
Difficulties with Breastfeeding
Problems with Partner or Immediate Family
Substance Use
Other (please specify below)
Other
Final thoughts - Please add any thing else you feel is relevant in your situation
Submit
