Sleep Intake Form Please enable JavaScript in your browser to complete this form.1. Client Name *2. Client Address3. Client Email and Phone Number *4. Baby's Name (both names if multiples) *5. Baby's Birth Date (if baby was early, please include original due date as well) *6. Baby's INTENSITY- How strong are your child’s emotional reactions? Do they laugh and cry loudly and energetically or softly and mildly? *Mild Reaction *Reactions are low key *"squeaks" when criesAverageIntense Reaction *Wails or explodes *Every reaction is powerful6. Parent's INTENSITY- How strong are your own emotional reactions? Do you laugh and cry loudly and energetically or softly and mildly? * Mild Reaction *Reactions are low keyAverage Intense Reaction *Every reaction is powerful6. Baby's PERSISTENCE- If your child is involved in an activity and you tell her to stop, does she stop easily or fight to continue? *Easily Stops *Can be redirected easily *Cry for a few minutes then stopsAverageLocks In *Can cry for hours *Won’t take “NO” for an answer *Doesn’t let go of an activity6. Parent's PERSISTENCE- If you are involved in an activity and you need to stop, is it easy for you to stop or do you keep going? *Easily Stops *Can be redirected easilyAverageLocks In *Doesn’t let go of an activity6. Baby's SENSITIVITY- How aware is your child of slight noises, emotions, differences in temperature, taste and texture? Do they react easily to certain foods, tags in clothes, irritating noises, or YOUR stress level? *Mildly Sensitive *Sleeps thru noise *Isn’t bothered by scratchy textures *Eats anything *Unaware of your stressAverageVery Sensitive *Needs quiet to sleep *Picky eater *Acts out to your stress *Strong reactions to how things feel6. Parent's SENSITIVITY- How aware is your child of slight noises, emotions, differences in temperature, taste and texture? Do they react easily to certain foods, tags in clothes, irritating noises, or YOUR stress level? *Mildly Sensitive *Sleeps thru noise *Able to manage others' stressAverageVery Sensitive *Needs quiet to sleep *Strong reactions to how things feel/sound/taste6. Current Sleep Routine- please check all the things you currently do to prepare your baby for sleep. *No Solids at Bedtime- solids can cause or exacerbate reflux, gas or tummy painTank Baby Up- cluster feed in the evening, do not feed in baby's bedroom to break sleep/feed associationBedtime between 6 and 7pmWhite Noise- sound machineDarken Baby's Room- especially for summer monthsClear out the crib- no toys, mobile, playthings in the cribLovey for baby- lovies with a face, big eyesLower temperature- cooler sleep environment helps baby sleep better (68* to 72*)Dream Feed- do not wake baby fully, when parents ready for bed, offer to feedReduce Stimulation- At least 1 hr prior to bedtime, quiet the home. Turn off TV, silence phones, dim lights. Bathe baby? Depends on temperament.Other (please specify)Submit Purchase Services Now!
