Sleep, Baby, Sleep Intake Form
Your full name
Your baby's name
What email address did you use for payment?
What email address will you be using for the consultation?
What is your baby's current daytime sleep schedule (if any)?
What does your baby's bedtime routine look like? Skip if you don't have one.
What type of sleep outfit does your baby sleep in?
What does your baby's sleeping arrangement look like? Please be specific.
How many hours does your baby sleep in a 24hr period. (Naps+ Night time sleep)?
Does your baby use a pacifier to sleep.
Yes, and I often have to reinsert it.
Yes, but it's not a prop. My baby doesn't mind or cry for it when it falls out.
No my baby does not use a pacifier.
Does your baby use any sleep props to fall asleep? or back to sleep during the night? Select all that apply.
Nursing to sleep
Bottle to sleep
Rocking to sleep
Bouncing, swaying, or any other movement
My baby does not use any props to fall asleep at bedtime or during the night
Which personality type best describes your baby. You may select more than one.
Quiet, mellow, laid back, doesn't mind change.
Cranky, fussy, rarely in a happy mood.
Clingy, anxious, often experiences separation anxiety.
Strong willed, stubborn, resists change.
Happy, playful, usually in great spirits.
Have you tried any other methods or programs?
What developmental milestones (if any) has your baby accomplished? Select all that apply
Holding head up when placed on belly
Rolling onto side
Rolling from belly to back
Rolling from back to belly
Sitting, but can't lay back down
Sitting, and knows how to lay back down
Standing, but can't sit back down
Standing, and knows how to sit back down
All of the above milestones
Which statement best describes how you feel about crying?
I don't mind hearing crying
I don't mind hearing some crying
I cannot hear any crying at all
Please provide in detail, any additional information that will help me understand what's going on with your baby's sleep troubles. If you have specific questions you can include them here too. If you forget to add something, no worries, you can always add additional information by emailing me.
How did you hear about Sleep Baby Sleep?
Did a friend refer you? If yes, please tell me your friends name so that I can give that person credit
Do you want to start the consultation on a particular date? If not, leave today's date and I will begin working on a sleep plan right away. *Keep in mind that once the sleep plan is sent, your consultation begins from that date.
Terms and Conditions
By checking off below you agree to the following terms and conditions: The information/advice provided during this consultation is not medical advice. The advice is for informational purposes only and is intended for use with healthy children with common sleep issues that are unrelated to medical conditions. The information provided is not intended nor is implied to be a substitute for professional medical advice. Always seek the advice of your physician with any questions you may have regarding a medical condition or the health and welfare of your baby. Also, please consult with and get approval from your pediatrician before following the advice or using the techniques offered during this consultation. In no event will Violet Giannone be liable to you for any claims, losses, injury or damages as a result of reliance on the information provided. All though all attempts have been made to verify the information provided is accurate, Violet Giannone does not assume responsibility for errors, omissions, or contrary interpretation of the subject matter within the consultation. Reliance on any advice given by Violet Giannone is solely at your own risk.
I agree to the terms and conditions
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