Your Name (Parents Name)?
Your Contact Number?
How did you hear about me?
Answer the following Questions!
1. What is your child’s name?
2. Age and date of birth?
3. Are there any health concerns? ( snoring, heavy breathing or other)
4. Is your child on any medication?
5. What would an average day of food consumption look like? Breakfast, snacks, lunch, dinner, treats?
6. What time is dinner?
7. Does your child have any snacks right before bed? If so, what?
8. Are there any developmental delays, behavioral issues or concerns about your child?
9. How does your child respond to instruction or disciple from you, and or, from others?
10. What time does your child start the day?
11. How does your child start the day? What is the first thing that you do once he wakes up in the morning?
12. Where does your child sleep, and does he/she share a room with anyone?
13. Where and when does your child watch TV or play on any other sorts of electronic devices?
14. Does your child ever take a daytime nap? If so, when and where? How long is this nap? How he falls asleep for this nap?
15. What time do you start the bedtime routine?
16. What are the steps of the bedtime routine?
17. What is the scenario when your child is falling asleep?
18. What time is he/she actually asleep?
19. What happens throughout the night? Best and worst-case scenarios
20. Do you keep the night light on during the night in your child’s bedroom
21. Do you feed your child during the night? How often?
22. On a scale of one to ten, with ten being extremely dark, how dark is your child’s room at bedtime, and through the night?
23. Was there a time when your child did sleep well, and things changed?
24. What would you like to see happening? What would be your main sleep goals for your child?
25. What are the most frustrating or difficult issues for you around your child’s current sleep habits?
26. Has your family experienced any major life changes or traumas that could be affecting your child?
27. Is there a family history of depression or anxiety disorders?
28. Are there any schedule challenges with getting your child to bed on time?
29. Is everyone in the household committed to seeing your child sleep well and on his/her own?
30. Is there anything else you’d like to share with me that you think I should know before we meet?