Existing Client Intake Form Existing Client Intake Form Existing Customer intake form 2Invoice Number of previous Consultation: Invoice numberDetails of Parents:Mother First Name Mother Surname Mother ID Number Mother OccupationPhysical Address MotherTelephone NumberMobile Number Father First Name Father Surname Father ID Number Father OccupationPhysical Address FatherTelephone NumberMobile Number Financial ResponsibilityWho will be responsible for paying the accountWho will be responsible for paying the accountMotherFatherBothOtherHow will the account be paidHow will the account be paidEFTCashPlease choose a support package?Please choose a support package?Baby Sitting (Per Hour)Day Sleep TrainingOne on One Consultation (In Person)Expectant parent trainingSleep training package (2 Nights)Night Sleep Training (Per Night)Night Nanny trainingOnline ConsultationWhatsup or email supportPlease enter PROMO CODE?Child DetailsHow many children are you completing this form for?One childTwinsMore than one childChild's Full NameDate of BirthCurrent WeightGenderMaleFemaleHave you previously completed the Mom's Lifeline Sleep Training Programme? Yes NoIf yes, please tell us a little more:Health & Medical InformationDoes your child have any allergies? Yes NoIf yes, please explain:Does your child have any special needs or take any medication? Yes NoIf yes, please provide details:Current Sleep RoutineWhat time does your child usually go to bed?How does your child usually fall asleep?Select all that applyMovementFeedingContact NapOtherNight WakingsNight Wakings: Give approx time and what happens, i.e. milk, rock, nappy change, walk to parents room, call to take to parents room, etcWake Up 1:Wake Up 2:Wake Up 3:Wake Up 4:Wake Up 5:How many times does your child currently feed during the night?01234More than 4Sleepwear & Sleep EnvironmentWhat does your child normally wear to sleep?Select all that applyBaby grow and blanketsPajamasSleep sackSwaddleLoose blankets or duvetOtherDoes your child use a pacifier to sleep?Select all that applyYes, and I often have to put it back inYes, but my child can put it back in independentlyNo, my child does not use a pacifierOnly during sleepOtherWhere does your child sleep?Select all that applyOwn room – cribOwn room – bedShares a room with siblingsShares a room with parentsBedshares with parentsCombination of aboveHow does your child usually fall asleep?Select all that applyNursing to sleepBottle to sleepRocking to sleepBouncing / Swaying / MovementFalls asleep independentlyOtherDoes your child use any other sleep props or objects to fall asleep? Yes NoIf yes, please explain:Does your child use delaying tactics at bedtime? Yes NoIf yes, please explain:How is your child currently getting their nutrition?Select all that applyBreastfeedingFormulaSolid foodsCombination of the aboveSince Your Last ConsultationHave you implemented any of the advice given during your previous consultation? Yes NoIf yes, please explain:What sleep training or changes have you tried since your last consultation?What results have you seen?Please describe what has happened since your last consultation and what you currently need help with. I confirm that I have read and understood the Mom's Lifeline Terms & Conditions. I consent to Mom's Lifeline processing my personal information and my child's information for the purpose of providing personalised sleep support.Submit Form
