Children's Sleep Behavior Questionnaire
Is your child afraid to sleep alone? Complete this form to provide information about your child's sleep problem. It takes about 5-10 minutes. We will not release your name, your child's name, or your email address.
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Email *
Name of parent completing this form
Today's date
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Name of child
Age of child
Please describe what concerns you most about your child's sleep problem.
Has your child ever had an established habit of sleeping alone? (Able to fall asleep alone and sleep the whole night without help from someone else, for at least 12 months in a row.)
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When did your child's sleep problem begin?
For each of the following questions, please describe your child's sleep behavior over the past month. (If you're not sure, estimate the number of nights.)
In the past 30 days, how many nights has your child slept in his/her bed the whole night, without disruption, and without needing reassurance or help from you after going to bed?
In the past 30 days, how many nights has your child been fearful or worried at bedtime or during the night (talking about fears, anxious crying)?
In the past 30 days, how many nights has a parent stayed with your child until he/she fell asleep?
In the past 30 days, how many nights has your child slept all or part of the night in YOUR BEDROOM (either in your bed or on the floor)?
In the past 30 days, how many nights has a parent slept all or part of the night in your CHILD'S BEDROOM?
In the past 30 days, how many nights has your child awakened during the night and needed your help to go back to sleep?
In the past 30 days, how many nights did your child complain of nightmares or scary dreams?
What does your child say he/she is afraid of?
About how long does your child take to fall asleep?  Estimate the number of minutes that is typical.
Does your child have anxieties or fears during the day? Ones that interfere with daily routines, require a lot of reassurance, take up time, or cause your child to avoid activities?
If YES, what causes your child to be anxious?
Has your child ever received psychological treatment or counseling?
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For the following questions, please tell us how you have been feeling about your child's sleep problems.
How bothersome or distressing has the problem been to mother (or caretaker #1)?
very little or not at all
very distressing
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How bothersome or distressing has the problem been to father (or caretaker #2)?
very little or not at all
very distressing
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How much does this problem interfere with sexual intimacy?
very little or not at all
very often or very much
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Overall, how disruptive has the problem been to family life?
very little or not at all
very often or very disruptive
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Has MOTHER (or caretaker #1) ever had the following problems?
Has FATHER (or caretaker #2) ever had the following problems?
Any comments or other important information?
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