New Client Intake Form New Client Intake Form New Client Intake FormChild DetailsName of the childDate of birthSex of ChildWeight of Child Position in Family? Position in Family?Only Child1st Child2nd Child3rd Child4th Child5th ChildHave you done a First Aid Course Have you done a First Aid Course ?YesNoAmount of children Amount of childrenOneTwoTwinsHave you tried any sleep training? Yes NoIf yes, Please Explain Sleep training? Does your child have any allergies? Yes NoAllergies of Child Parent Details:Parent 1Name Parent 1 Surname Parent 1 ID Number Parent 1Physical Address Parent 1Email Address Parent 1Telephone Parent 1Mobile Number Parent 1Occupation Parrent 1Parent 2Name Parent 2 Surname Parent 2 ID Number Parent 2Physical Address Parent 2Email Address Parent 2Telephone Parent 2Mobile Number Parent 2Occupation Parrent 2Financial ResponsibilityWho will be responsible for paying the account Who will be responsible for paying the accountParent 1Parent 2BothHow will the account be paid How will the account be paid?EFTCashPlease choose a support package? Please choose a support package?Online ConsultationOne on One Consultation (In Person)Sleep training package (2 Nights)Day Sleep TrainingNight Sleep Training (Per Night)Whatsup or email supportPlease enter PROMO CODE?Sleep & FeedingHow many hours does your child sleep in 24 hour cycleWhat is your child's current sleep schedule? Do you have a bedtime routine for your child? Yes NoMorning wakeup time?How many day naps?What time?First Nap?Second Nap?Third nap?What is your baby’s dress code for the night? Blankets Sleepsack SwaddleWhere does your baby sleep? In own room in crib Room sharing with parents Co sleeping with parents In own room in bed In room sharing with sibling’sAny night wakings? Yes NoIf Yes. How many times?Breast feeding Yes NoBottle feeding? Yes NoDoes your child fall asleep during a feed? Yes NoDoes you child fall asleep whilst rocking? Yes NoIs your child using dummy? Yes NoDo you often have to reinsert it? Yes NoDoes he use the dummy only for sleep? Yes NoDoes your Child put the dummy back himself when the dummy fall out? Yes NoDoes your child have a soft toy as sleep friend? Yes NoDoes your child still wake up at night? Yes NoHow many times? What do you do to get him to go back to sleep?Is your child on solids yet? Yes NoIf yes, give examples of what he/she eatsCan your child fall asleep without physical touch or intervention from you? Yes NoWhen your child is asleep initially, what happens the rest of the night? Who are your support system and look after your child when you can not? Who are your support system and look after your child when you can not?A NightnurseNannyAu PairGrand ParentsSchoolCrecheDay MotherDoes your child use a pacifier to sleep? yes, I often have to reinsert it. Yes, but my baby don't cry or mind when it falls out. No, my baby does not use a pacifier. OtherDoes your child use any other sleep props to fall asleep? Or to fall back to sleep during the night? Select all that apply. Nursing to sleep Bottle to sleep Rocking to sleep Bouncing, swaying, or any ither movement My baby falls asleep independently during day or night Other, please specifyIf Other, Please elaborate here? *Is child still feeding at night? Is child still feeding at night? *YesNoif so, how many feeds and what times How is your child currently getting his/her nutrition? Select all that apply. (Please note all feeding instructions should advisor) be handled by your pediatrician or health. Breastfeeding Formula Solids OtherSolids Medication / Nutritional Supplements Which personality type best describes your child. You may select more than one. Quiet, mellow, laid back, does not mind change Cranky, fussy, rarely in a happy mood Clingy, anxious, often experiences seperation anxiety Strong willed, stubborn, resists change.What developmental milestones (if any) has your child accomplished? Select all that apply? None Yet 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 Crawling Standing, but can't sit back down Standing, and knows how to sit back down Walking All of the above OtherHave you tried any methods or programs to better your baby's sleep?Have you tried any methods or programs to better your baby's sleep?YesNoHow would you describe your pregnancy journey?Easy, Enjoyed being pregnant Yes NoDifficult with complications Yes NoWhich statement best describes how you feel about crying?Which statement best describes how you feel about crying? *I don’t mind hearing cryingI don’t mind hearing some cryingI cannot hear any crying at allItem 1Any Additional info you would like to share about your pregnancy? Where do you struggle the most?Where do you struggle the most?Day napsDay napsBoth1st APGAR scoring out of 10? 2nd APGAR scoring out of 10? Please provide in detail, any additional information that will help me understand what's going on with your baby's sleep challenges. If you have specific questions you can include them here too. If you forget to add something, don't worry you can email me the additional information as well.How did you hear about Mom's Lifeline? By selecting this box, you agree to the following terms and conditionsSubmit Form
