New Client Intake Form

Requirement for baby

Name of the child *

Date of birth *

Sex of Child *

Weight of Child *

Position in Family? *

Have you done a First Aid Course *

Amount of children *

NOTE: If more than two children, two forms needs to be completed

Have you tried any sleep training *

If yes, Please Explain Sleep training? *

Allergies of Child *

Special needs of Child *

Details of Parent 1

Name Parent 1 *

Surname Parent 1 *

ID Number Parent 1 *

Physical Address Parent 1 *

Occupation of Parent 1

Email Address Parent 1 *

Email Address

Telephone Parent 1 *

Mobile Number Parent 1 *

Occupation Parrent 1 *

Details of Parent 2

Name Parent 2 *

Surname Parent 2 *

ID Number Parent 2 *

Physical Address Parent 2 *

Occupation of Parent 2

Email Address Parent 2 *

Email Address

Telephone Parent 2 *

Mobile Number Parent 2 *

Occupation Parent 2 *

Financial Responsibility

Who will be responsible for paying the account *

How will the account be paid *

Please choose a support package? *

Please enter PROMO CODE?

What is your child' current daytime sleep schedule? *

What does your child's bedtime routine look like? *

What outfit does your child wear when sleeping? *

What does your child's sleeping arrangement look like? (Please be specific) *

How many hours does your child sleep in a 24 hour period. Also Indicate what is day and what is night. *

When 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? *

Please indicate if your child is only using the dummy for day or night or both?

Does 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.

Other

Does 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 other movement

My baby falls asleep independently during day or night

Other, please specify

If Other, Please elaborate here? *

Is child still feeding at night? *

if 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

Other

Solids *

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 separation anxiety

Strong willed, stubborn, resists change.

Have you tried any methods or programs to better your baby's sleep? *

Which statement best describes how you feel about crying? *

How would you describe your pregnancy? *

Any Additional info you would like to share about your pregnancy? *

Where do you struggle the most? *

1st 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? *

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