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New Client Intake Form

Please complete the questionnaire as accurately as possible. The information you provide helps us understand your child’s current sleep patterns, routines, personality and needs so that we can provide personalised sleep support.

Takes 15–20 minutesConfidential & securePersonalised support

Leave this field empty

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

Cellphone Number*

Father’s details

Where applicable. Leave blank if not applicable.

Father First Name

Father Surname

Father ID Number

Father Occupation

Physical Address

Email Address

Telephone Number

Cellphone 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.

Name of the child*

Date of birth*

Current weight of child

Birth weight

Gender

Have you previously tried any sleep programmes or sleep-training methods with your child?

YesNo

Is your child currently eating solid foods?

YesNo

Does your child have any allergies?

YesNo

Does your child have any special needs?

YesNo

Is your child currently taking any medication or supplements?

YesNo

Daily routine & sleep associations

Describe a typical day and night as it currently is.

What time does your child usually start their day?

What time does your child usually go to bed?

How does your child usually fall asleep during the day?

Tick every option that applies.

MovementFeedingContact / being heldOther

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

Daytime naps

Choose when each nap usually starts and ends — the length is worked out for you. Leave any naps your child doesn't have empty.

Nap 1

Starts

Ends

Length: —

Nap 2

Starts

Ends

Length: —

Nap 3

Starts

Ends

Length: —

Nap 4

Starts

Ends

Length: —

Total daytime sleep: —

Awake time

How long your child is awake between sleeps, worked out from the wake-up time, nap times and bedtime above.

Wake-up → Bedtime—

Total awake time: —

Are your child’s daytime naps inconsistent?

YesNo

How does your child usually fall asleep at night?

Tick every option that applies.

MovementFeedingContact / being heldOther

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?

Are your child’s night wakings inconsistent?

YesNo

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.

Babygrow and blanketsPajamasSleep sackSwaddleLoose blankets or duvet

Where does your child sleep?

Tick every option that applies.

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

Does your child use a pacifier to sleep?

Tick every option that applies.

No, my child does not use a pacifier.Yes, only for sleep.Yes, I often have to reinsert it.Yes, my child can put it back in themselves.Other

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

Sleep props & settling

What your child relies on to fall asleep.

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

Tick every option that applies.

Nursing to sleepBottle to sleepRocking to sleepBouncing, swaying, or any other movementMy baby falls asleep independently during day or nightOther, please specify

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

Which personality traits best describe your child?

Quiet, mellow and laid-back; generally does not mind change.Cranky or fussy; rarely in a happy mood.Clingy or anxious; often experiences separation anxiety.Strong-willed or stubborn; tends to resist change.Happy and playful; usually in great spirits.Other

Please tell us anything else about your child’s personality that you feel is important.

Does your child use delaying tactics at bedtime?

YesNo

Which statement best describes how you feel about hearing your child cry?

Tick every option that applies.

I don't mind hearing crying.I don't mind hearing some crying.I cannot hear my child cry at all.Other

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

How is your child currently getting their nutrition? (Select all that apply)

Tick every option that applies.

BreastfeedingFormulaSolidsOther

Birth & medical background

This helps us rule out physical causes before changing routines.

How would you describe your pregnancy?

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

1st APGAR scoring out of 10?

2nd APGAR scoring out of 10?

If you know the details, please provide any relevant information about the APGAR scores.

Were you iron deficient during or after your pregnancy?

YesNo

Please provide any additional information or specific questions that will help us better assist you.

How did you hear about Momslifeline?

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].

How the process works

Complete Intake Form

Share details about your baby, routine, and challenges.

Personal Review

Erica reviews your information carefully — no automated responses.

Your Sleep Plan

Meeting to discuss the submitted questionnaire with findings, advice, how, when etc.

Ongoing Support

You’re supported every step of the way.

Please note that submitting an intake form does not automatically start a support package. Erica will review your information and contact you to discuss the best option for your family. You are welcome to browse the sleep services in the meantime.