Child Sleep Questionnaire Step 1 of 6 16% Child's name* First Last Boy or Girl?BoyGirlChild's date of birth* DD MM YYYY Child's ageParent 1 (You)Parent 1 (you): name* First Last Parent 1 (you): date of birth* DD MM YYYY Parent 1 (you): relationship statusMarriedLiving with partnerDivorcedSeparatedWidowedParent 1 (you): address* Address line 1 Town / City Postcode Parent 1 (you): phone number*Parent 1(you): mobile numberParent 1 (you): email address* Enter Email Confirm email address Parent 1 (you): occupationParent 1 (you): support systemParent 2Parent 2: name First Last Parent 2: date of birth DD MM YYYY Parent 2: relationship statusMarriedLiving with partnerDivorcedSeparatedWidowedParent 2: address Address line 1 Address line 2 Town / City County Postcode Parent 2: phone numberParent 2: mobile numberParent 2: email address Enter email address Confirm email address Parent 2: occupationParent 2: support systemOther members of your householdPlease provide the names, genders and ages of the other members of your family, listing first the child whose sleep habits you are seeking help for:What is the best phone number to reach you in the morning for follow-ups?How did you hear about The Sleep Works, or who referred you? Save questionnaire and continue later? History 1. Prenatala) Was this a planned pregnancy?YesNob) Were there any problems during the pregnancy?YesNoPlease describe the problems experienced:c) Delivery/labor:VaginalC-SectionVBACd) Were there any complications during delivery/labor?YesNoPlease describe the problems experienced:2. Was your child born full term?YesNoHow many weeks premature?3. Were there any medical problems for your newborn at birth?YesNoPlease describe the problems experienced:4. The following three questions are for Muma) Are you able to sleep at night when your child is sleeping?b) How is your appetite?c) Are you having any troubling or scary thoughts?Your Doctor's DetailsDoctor's name First Last Doctor's address Address line 1 Address line 2 Town / City County Postcode Doctor's phone number Save questionnaire and continue later? Development and Health History 1. Approximately when did your child reach the following milestones (where applicable)?a) Rolloverb) Sit Upc) Crawlingd) Standinge) Walking2. Feedinga) Is your child:Formula fedBreast fedBothNeither / weanedb) Has your baby started solids?YesNoAt what age?3. a) What is your child's current weight?3. b) What percentile are they in?4. Does your child:a) Suck their thumb/fingers?YesNob) Use a dummy?YesNoc) Have a security object, i.e. blanket or stuffed animal?YesNo5. Does (or did) your child have reflux problems or colic?YesNoHow long did it last?When was it resolved?What helped?6. Does your child have any of the following? Allergies Frequent ear infections Asthma Frequent or constant stuffy nose 7. Any past or current medical or developmental problems?YesNoPlease describe:8. Does your child take any medication on a regular basis?YesNoPlease describe: Save questionnaire and continue later? Sleep Habits1. Does your child wet the bed (if potty trained) during the night?YesNoHow often? And is there a pattern to the bedwetting?2. Does he/she sleepwalk?YesNoHow often? And at what time?3. Does your child snore?YesNo4. Does your child mouth breathe?YesNo5. Does your child fall out of bed?YesNo6. Is your child a restless sleeper?YesNo7. Does your child sweat while sleeping?YesNo8. Does your child have nightmares?YesNoHow often? And at what time during the night?SchedulePlease describe in detail your current typical 24-hour schedule with your child - from waking up to through the night.Please include feeding amounts, breastfeed vs bottle if you do both, and times fed. Also include what you do to try to help your child settle to sleep. Save questionnaire and continue later? Other Questions1. Are your child's sleeping disturbances new or have they been ongoing since infancy?2. What techniques have you tried up to this point to address your child’s sleep problem?3. Answer the following questions a) to h) only if they weren't covered in your responses to the 'Schedule' question on the previous page.a) Is your child in a cot or a bed?CotBedb) Where does your child sleep?c) If your child sleeps in your bed, does your spouse see this as a problem or something they want to change?d) And do you see this as a problem or something you want to change?e) Does your child's sleeping location change during the evening/night? For example, does he/she fall asleep in your bed and then have to be moved to his/her own bed? Or does he/she fall asleep in his/her own bed and then come into your bed during the night?f) Does he/she share a bedroom with a parent, brother, sister or someone else?g) Does he/she stay in his crib/bed without trying to get out?h) Does he/she get out of bed during the night?YesNoWhere does he/she go?4. How do you get him/her to sleep? Describe the routine:5. How long before bedtime do you start this routine?6. Is there a fixed bedtime?YesNoAt what time?7. If you have other children, do they go to bed at the same time?YesNo8. Is your child afraid of the dark?YesNo9. Do you leave a light on, or the bedroom door open?YesNo10. Is your child distressed when he/she is left alone in his/her cot or bed?YesNoWhat do you do when they're distressed?11. Does your child head bang or rock his/her body?YesNo12. How would you describe your child's temperament?13. How does your child handle time by himself/herself?14. Are there rituals or certain things that your child does to self-soothe?15. Do any of your other children currently have (or previously had) problems with sleep?YesNoWhat did you do to address those problems?16. Are both parents in support and willing to participate in helping your child learn to sleep through the night?YesNo17. What is the ultimate outcome you and your spouse would like to see with regard to your child’s sleep habits? Please be specific. For example: what would you like your child’s sleep schedule and sleep habits to look like at the conclusion of treatment? Save questionnaire and continue later? Sleep Consultant Contract & Letter of Agreement As Sleep Consultants, we are dedicated to help you improve your child’s sleep. This letter is our agreement regarding our services. We agree to the following: Our Services: Following a free preliminary phone conversation to discuss your child’s current sleep situation and options for how we can help, we will send you an email with a link to the Sleep Questionnaire to complete online, including an overview of your child’s current sleep situation over a 24-hour period, and this Letter of Agreement for your e-signature. Following submission of the completed questionnaire to us, you can go to our website to book a consultation date. Please allow at least 3 days after submission of your questionnaire for the consultation date, in order to enable us to process the questionnaire and adequately prepare for our consultation. During the consultation, we will discuss this background information; we will explain sleep basics and the specific areas of your child’s sleep to focus on, tips and suggestions flagged up from the questionnaire and our discussions, suggested framework for your child’s day, and options for sleep training approaches. We will answer any questions you have, and together we will create a plan to improve your child’s sleep. After the consultation, a copy of the sleep plan will be sent to you by email. After the initial consultation, we offer either a package with 1 follow-up call, or a package of unlimited follow-up support by email and phone as you progress through the plan (for up to 2 months). During these follow-ups, we will review how the plan is progressing and discuss possible tweaks to it, if necessary. 1. Your Role: You agree to the following participation in order for the Sleep Plan to be effective: Keep a sleep/wake log during the weeks we are working together. Carry out the steps in the Sleep Plan that we have developed together consistently. Communicate openly with me with any questions or concerns you have about your child’s sleep, including any medical, health, or emotional situations that may arise. Discuss your experiences during the plan, so we can make necessary adjustments. Dedicate approximately 3 weeks to sleep training without travelling or any major family or work events and make your child’s sleep a priority during that time. You acknowledge and understand that the effectiveness of sleep coaching depends on your consistent follow-through, both during and after our work together, although there can never be a 100% guarantee of success. 2. Fees: Our fee structure offers the choice between a Consultation + 1 follow-up call (Standard Package) or Consultation + follow-up support (Plus Package). Child Sleep Standard Package: £200 (for 1 child; please contact us for details of packages for 2 or more children) Review of Sleep Questionnaire and Sleep Logs (submitted prior to consultation). 1½ - 2 hour consultation by Skype or Facetime with a camera (or in-home, depending on location. Discussion of sleep basics, your questions, and the challenges you and your child faces. The creation of a detailed, individualised sleep plan tailored to your goals and needs. 1 follow-up call during the sleep plan. Child Sleep Plus Package: £300 (for 1 child; please contact us for details of packages for 2 or more children) As above plus: Follow-up support calls or emails for up to 2 months. Individual calls after this will cost £25 for half an hour. Please note: The success of Sleep Coaching will depend on your ability to be consistent while following your Sleep Plan. The support offered to you during the follow-up calls and emails is usually invaluable and highly recommended, will make the Sleep Coaching more effective, and will help ease the process for you and your partner. 3. Payment Method and Expenses: Fees are to be paid before the consultation by bank transfer. For face-to-face consultations, we will also accept cash. 4. Contacting us for follow-up sessions: We will correspond by email, WhatsApp or text and will schedule in phone calls at specific, mutually convenient times. We are generally available between 9am-2pm, some mid-week evenings, and at limited times over the weekend. 5. Cancellations: If you need to cancel or reschedule your consultation, please notify us as soon as possible so that we can offer your appointment to another tired family. 6. Insurance: Regrettably, we are unable to accept insurance proceeds. You may however submit our invoices to your insurance company, but we cannot guarantee reimbursement for our fees or for any expenses you may incur during the coaching. 7. Confidentiality: We will keep all information we share confidential. You understand there are circumstances that may require us to disclose information (for example, by law or pursuant to a court order). If that occurs, we shall be released from this obligation, but only to the extent of the information we are required to disclose. 8. Our services are not medical advice: You understand that we are not medical professionals and will not advise you on medical conditions, or make medical diagnoses. You also understand that your child’s sleep patterns or sleep difficulties may be symptomatic of a condition for which medical intervention or treatment is advisable. If you have any reason to believe that your child’s sleep difficulties may be related to a medical condition, or that your child has health concerns that may be adversely affected by sleep coaching, it is strongly advised to consult with your child’s doctor before beginning the sleep coaching process. You are solely responsible for discussing any possible medical conditions with your child’s doctor or other health professional. You understand that you assume primary responsibility for the health of your child and, to the extent permitted by law, you will not hold us or our consultancy responsible for any outcomes resulting from complications that are outside of our control. 9. Disclaimer: To the extent permitted by law, The Sleep Works expressly disclaims any liability, loss, damage, or injury caused by information provided to the client. 10. Entire Agreement: This letter reflects the entire understanding between us and may only be changed in writing, signed by both of us. If a court decides any of the terms are unenforceable, we agree that these terms will be severable from the agreement and all other terms of our agreement will remain in effect. 11. Termination: This agreement will terminate automatically upon completion of the services required by this Letter of Agreement. Please acknowledge your agreement and understanding of these terms by signing below. We look forward to helping you and your family to make a gentle transition to a restful night’s sleep for you and your child. Yours sincerely, Maryanne Taylor Founder and Sleep Consultant, The Sleep WorksTick box to confirm* I/We have read this letter describing The Sleep Works' services and limits to service and agree that it reflects the discussions we have had and our agreement to the terms of this letter. * REQUIRED: By submitting this form, you consent to your information being stored in The Sleep Works' customer database. Accepted and agreed (your signature)*Use your mouse cursor, or your finger/stylus if you're on a touchscreen device, to write your signature in the field above.Date* DD MM YYYY Client name* First Last EmailThis field is for validation purposes and should be left unchanged. Save questionnaire and continue later?