Sleep Questionnaire

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Sleep Questionnaire

In this brief questionnaire, we will ask you about your current sleep habits and gather some basic information to better assist you on your journey to improved sleep.

Email *

What challenges are your currently experiencing with your sleep?

Select ALL that apply

I don't have a specific problem, but I want to optimize my performance by improving my sleep.

It takes me too long to fall asleep

I wake up during the night

My mind races at night

I have a young kid(s) of course I'm not sleeping

I am relying on substances like supplements, drugs, or alcohol to get to sleep

I work shift work

I feel like I get enough sleep, but I'm still exhausted

Other:

Over the last month, how many hours of sleep have you been averaging each night?

Less than 5

5 - 6

6 - 7

7 - 8

8 - 9

9 +

Clear selection

Select your age range

18 or younger

19 - 25

26 - 35

36 - 45

46 - 55

56 - 65

66 - 75

76 +

Clear selection

Are you interested in private sleep coaching or group programs

Private Sleep Coaching

Group Programs

BOTH!

Neither sound like what I'm looking for

Clear selection

What is your first and last name? *

What is your email? *

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms