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TLC Information Form for Sleep Consultations
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* Indicates required question
Email
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Your email
Caregiver's First Name:
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Your answer
Caregiver's Last Name:
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Your answer
Other Caregiver's Name:
Your answer
Best Phone # to Reach You:
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Your answer
Child's Name:
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Your answer
Child's Age:
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Your answer
Is your child adopted?
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Yes
No
Was your child premature?
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Yes
No
If you answered "YES" to the above question, how many weeks premature was your child?
Your answer
Your child's birth weight:
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Your answer
Your child's current weight:
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Your answer
Does your child have any siblings? If so, what are their names and ages?
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Your answer
Did your child have colic?
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Your answer
Have there been any other health issues or concerns?
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Your answer
Is your child on any medication?
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Your answer
Does your child have any allergies or food sensitivities?
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Your answer
How would you rate your child's eating habits? (picky eater, healthy appetite, only eats same 5 things...)
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Your answer
Have you spoken to your doctor about your child's sleep difficulties?
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Your answer
What is your pediatrician's name? (They will not be contacted.)
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Your answer
Does your child have a lovie/transitional object?
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Your answer
Does your child snore or is he/she a heavy mouth breather?
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Your answer
Does your child have any sleep props or associations?
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Your answer
Where does your child sleep? Does she/he share a room with anyone?
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Your answer
What time does your child start his/her day?
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Time
:
AM
PM
What happens at this time? Are they given a bottle, breastfed, start with solids?
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Your answer
What signals do you notice your child gives when she/he is tired?
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Your answer
What time of day does the first nap usually occur and where does it take place?
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Your answer
How do you get your child to sleep for this first nap?
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Your answer
How long does this nap last?
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Your answer
What time of day does the second nap occur?
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Time
:
AM
PM
How does your child fall asleep for this nap?
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Your answer
How long does this nap last?
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Your answer
Is there a third or fourth nap during the day or early evening?
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Your answer
How does your child fall asleep for these naps?
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Your answer
What time do you start getting your child ready for bed?
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Time
:
AM
PM
What do you do with your child when getting them ready for bed? (For example: bath, brush teeth, sing songs, read stories, play a game, etc.)
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Your answer
What time does your child actually fall asleep at bedtime?
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Time
:
AM
PM
How does your child fall asleep at this time?
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Your answer
What happens during the night? (Best AND worst case scenarios.)
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Your answer
Have you read any books about infant sleep and have you tried any suggestions from these books in the past?
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Your answer
Was there a time when your child slept well and then things changed?
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Your answer
Sleep Goal #1:
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Your answer
Sleep Goal #2:
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Your answer
Is there anything else you would like to share that you think I should know before we meet?
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Your answer
Have you received one-on-one support from a TLC professional previously? If yes, please provide the name of the professional.
Your answer
How did you hear about The Loved Child, LLC?
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I have participated in The Loved Child's programs previously
Pediatrcian's office or other healthcare/wellness setting
Social Media (e.g. Facebook, Instagram etc.)
Friend/family member
Pamphlet/flyer
Search engine (Google, Yahoo, etc.)
Other:
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