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Special Needs Sleep Program
Hi there,
Thanks so much for your interest in the Special Needs Sleep Program! I am looking forward to helping you and your family get the best night's sleep possible.
Please be so kind as to fill out this application to the best of your abilities with regards to your child's sleep. As soon as this form is complete, you'll get an email to schedule your discovery call with me. Then we can talk about how the Special Needs Sleep Program will help you and your family!
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Email
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Your email
Your Name
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Your answer
Where are you located (City, State, Country)?
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Your answer
Your child's name
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Your answer
How old is your child?
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Your answer
What is your child's diagnosis?
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Your answer
Was your child born full term, or prematurely?
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Your answer
What is your child's current weight? (It doesn't have to be exact)
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Your answer
Does your child currently have issues gaining weight, or was this an issue in the past?
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Your answer
Is your child eating well?
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Your answer
Does your child have any major health concerns or issues now, or in the past? (Examples of this are heart/lung issues, chronic constipation, etc.)
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Your answer
When sleeping at night, do your child doing any of the following?
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Grind teeth
Thumb sucking
Snoring
Gasping
Sleeping with mouth open
Other:
Required
Is your child currently on any medication?
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Your answer
Does your child take melatonin to sleep?
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Yes
No
Only when needed
Right now, what does a typical night look like for your child? This can include how long it takes them to sleep, how many nighttime wake ups, if you help your child to get to sleep. Feel free to give details here, the more the better!
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Your answer
How do you put your child to sleep each night? What's your usual routine?
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Your answer
Where does your child sleep usually?
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Your answer
If your child naps, how are naps going during the day?
Your answer
In an ideal situation, what would you like your child's sleep to look like? What would be your top 3 goals? Be specific - I want to make sure that the Special Needs Sleep Program is going to help you achieve these :)
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Your answer
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