New Client Intake Form New Client Intake Form New Client Intake Form 2Before You BeginPlease 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.Parent DetailsMother First NameMother SurnameMother ID NumberMother OccupationPhysical AddressEmail AddressTelephone NumberCellphone NumberFather First NameFather SurnameFather ID NumberFather OccupationPhysical AddressEmail AddressTelephone NumberCellphone NumberPayment DetailsWho will be responsible for paying the account?MotherFatherBothHow will the account be paid?EFTCashPlease 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)Day Sleep TrainingNight Sleep Training (Per Night)Night Nanny trainingOnline ConsultationWhatsup or email supportPlease enter PROMO CODE?Your Child's DetailsHow many children are you completing this form for?Please selectOne childTwinsMore than one childWhat would you like help with?Please selectDay sleepNight sleepBoth day and night sleepName of the childDate of birthCurrent Weight of Child Birth WeightGenderGenderMaleFemaleHave you previously tried any sleep programmes or sleep-training methods with your child? Yes NoIf yes, Please ExplainIs your child currently eating solid foods? Yes NoIf yes, please provide some examples of the foods your child eats.How is your child currently getting their nutrition? {Select all that apply.) Breastfeeding Formula Solids OtherDoes your child have any allergies? Yes NoAllergies of Child Does your child have any special needs? Yes NoIf yes, please provide details.Is your child currently taking any medication or supplements? Yes NoIf yes, please list them.Your Child's Daytime RoutineWhat time does your child usually start their day?How does your child usually fall asleep during the day? Movement Feeding Contact / being held OtherIf you selected "other", please tell us more.Daytime NapsNap 1Nap 2Nap 3Nap 4Are your child's daytime naps inconsistent? Yes NoIf you selected "Yes", please tell us more.Night-Time RoutineWhat time does your child usually go to bed?How does your child usually fall asleep at night? Movement Feeding Contact / being held OtherIf you selected "other", please tell us more.Night WakingsPlease tell us about your child's night wakings. For each waking, please provide 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? Night Wake-Up 1Night Wake-Up 2Night Wake-Up 3Night Wake-Up 4Night Wake-Up 5Are your child's night wakings inconsistent? Yes NoHow many feeds does your child currently have during the night?01234More than 4What does your child normally wear to sleep? Babygrow and blankets Pajamas Sleep sack Swaddle Loose blankets or duvet Combination of the aboveWhere does your child sleep? Own room in a crib Own room in a bed Shares a room with siblings Shares a room with parents Bedshares with parents Combination of the aboveDoes your child use a pacifier to sleep? 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. OtherDoes your child use any other sleep props to fall asleep? Nursing to sleep Bottle to sleep Rocking to sleep Bouncing, swaying, or any ither movement My baby falls asleep independently during day or night Other, please specifyIf you selected "Other", please explain.Your Child's PersonalityWhich personality traits best describe your child?You may select more than one.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.OtherPlease tell us anything else about your child's personality that you feel is important.Does your child use delaying tactics at bedtime? Yes NoIf yes, please explain.Which statement best describes how you feel about hearing your child cry? I don't mind hearing crying. I don't mind hearing some crying. I cannot hear my child cry at all. OtherIf you selected "Other", please explain.Pregnancy & BirthHow would you describe your pregnancy? Easy Emotionally difficult for Mom Baby was in distress Mom and baby were in distress OtherIf you selected "Other", please explain.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? Yes NoIf yes, please provide any relevant details.Please provide any additional information or specific questions that will help us better assist you.How did you hear about Mom's Lifeline? Word of mouth Facebook Instagram Website Physician / healthcare professional Other 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
