Leave this field empty

Invoice details

So we can match this form to your existing file.

Invoice number*

Mother’s details

Please complete as accurately as possible.

Mother First Name*

Mother Surname*

Mother ID Number

Mother Occupation

Physical Address

Email Address*

Telephone Number

Mobile Number*

Father’s details

Where applicable. Leave blank if not applicable.

Father First Name

Father Surname

Father ID Number

Father Occupation

Physical Address Father

Email Address

Telephone Number

Mobile Number

Account & package

This helps us prepare the correct quotation.

Who will be responsible for paying the account?

How will the account be paid?

Please choose a support package*Unsure? Choose “Not sure yet — please advise”.

Please enter PROMO CODE

How many children are you completing this form for?One section per child will be sent to Erica, so she has full details for each.

Your child’s details

The more detail you give here, the more personalised the plan.

Child's full name*

Date of birth*

Current weight

Gender

Have you previously completed the Momslifeline Sleep Training Programme?

YesNo

Does your child have any allergies?

YesNo

Does your child have any special needs or take any medication?

YesNo

What time does your child usually go to bed?

How does your child usually fall asleep?

Tick every option that applies.

MovementFeedingContact NapOther

If you selected “Other”, please explain.Only needed if you chose “Other” above.

Night Wakings

Give the approximate time and what happens when your child wakes.

For example: does your child need milk, a nappy change, rocking, walking to your room, or do they call for you to take them to your room?

How many times does your child usually wake up at night?

Do you have a nanny or night nurse?

YesNo

How many feeds does your child currently have during the night?

What does your child normally wear to sleep?

Tick every option that applies.

Baby grow and blanketsPajamasSleep sackSwaddleLoose blankets or duvetOther

Where does your child sleep?

Tick every option that applies.

Own room – cribOwn room – bedShares a room with siblingsShares a room with parentsBedshares with parents

Does your child use a pacifier to sleep?

Tick every option that applies.

Yes, 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 sleepOther

If you selected “Other”, please explain.Only needed if you chose “Other” above.

Progress since your last consultation

What has changed and what you still need help with.

Have you implemented any of the advice given during your previous consultation?

YesNo

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.

Does your child use any other sleep props or objects to fall asleep?

YesNo

Does your child use delaying tactics at bedtime?

YesNo

Your answers are saved on this device as you go, so you can come back and finish later. They are only sent to Erica when you submit.

Confirmation & consent

Please read and confirm before submitting. Required.

I confirm that I have read and understood the Momslifeline Terms & Conditions. I consent to Momslifeline processing my personal information and my child’s information for the purpose of providing personalised sleep support, in accordance with POPIA.

By submitting you also confirm that:

I understand that Momslifeline provides educational sleep consultancy and that this does not replace medical advice, diagnosis or treatment.
I understand that I remain responsible for decisions regarding my child’s care, health, safety and sleep environment.
I agree not to copy, distribute or share personalised sleep programmes or materials without written permission.

Takes 15–20 minutes. Your information is confidential.

Having trouble submitting? Email the details to [email protected] or call 072 616 2451 and we will complete it with you.

Your progress

Before you begin

· Your baby’s routine and sleep patterns
· Feeding details
· A quiet 15–20 minutes to complete the form

Your answers are saved on this device after each step, so you can stop and come back later.

Rather talk first?

Call 072 616 2451 or email [email protected].

Existing Client Intake Form

Invoice details

Mother’s details

Father’s details

Account & package

Your child’s details

Night Wakings

Progress since your last consultation

Confirmation & consent

3 Quick Wins for Better Baby Sleep