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CLIENT INTAKE QUESTIONAIRE

Requirement for baby

Details of Mother


 

Occupation of Mother

Details of Father

Occupation of Father

Financial Responsibility


 


 


 


 


 

Does your baby use a pacifier to sleep?

 

Does your baby use any other sleep props to fall asleep? Or to fall back to sleep during the night? Select all that apply.

 

How is your baby currently getting his/her nutrition? Select all that apply. (Please note all feeding instructions should advisor) be handled by your pediatrician or health .

 

Which personality type best describes your baby. You may select more than one.

 


 

What developmental milestones (if any) has your baby accomplished? Select all that apply?

 


 


 


 


 

By signing below, you agree to the following terms and conditions:

Disclaimer:

The information/advice provided during this consultation is not medical advice. You are not establishing a medical professional/patient relationship.

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 medical condition or the health and welfare of your baby.

Pediatrician Approval:

You agree to consult with and get approval from your pediatrician before following the advice or using the techniques offered during the consultation.

Legal Notice:

In no event will Mom's Lifeline 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, Mom's Lifeline does not assume responsibility for errors, omissions, or contrary interpretation of subject matter within the consultation. Reliance on any advice given by Moms lifeline is solely at your own risk.

Refund policy:

Due to the amount of time, effort, and commitment provided within a consultation, refunds are not possible once this form is submitted.

Copyright notice:

The information provided within the consultation may not be reproduced, republished, or transmitted in any form or by any means mechanical or electronic, including photocopying and recording, or by any information storage and retrieval system, without permission.

All information supplied by Mom's Lifeline either verbally, written or implied always remains the property of Mom’s Lifeline. Written permission is required to reproduce, record, publish or advise verbally any details of the provided sleep plan, E-guides, charts, notes, advice offered or consultation transcript or summary in any format whatsoever.  This includes but is not limited to any details published on any blogs, forums, or similar boards. Any information by Moms lifeline is confidential.

Any passing on any information to anyone is strictly forbidden and subject to international copyright laws.

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Disclaimer: This website does not provide medical advice. Always seek the advice of your pediatrician or other qualified health provider with any questions you may have regarding a medical condition or the health and welfare of your child.

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