Sleep Consulting Contract

Parent's Name*

First NameLast Name

Parent's Pronoun(s)*

Phone Number*

Area CodePhone Number

Email*

example@example.com

Parent's Name (if applicable)

First NameLast Name

Parent's Pronoun(s) (if applicable)

Phone Number

Area CodePhone Number

Email

example@example.com

Baby/Child's Name (if already chosen)

First NameLast Name

DOB*

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What does your child's current sleeping arrangement and "typical" night of sleep look like? Please tell me any sleep issues/habits currently present you would like to change.

Please list all locations where your child sleeps.

What are you sleep goals with your child? (Sleeping where? Night feedings? How many wakes?)

What have your tried so far? For how long? What has worked? Not worked? Please be thorough.

By signing below you are stating you understand and accept that Jessica Mascher will provide consulting services in infancy and early childhood issues and challenges only. All consulting is confidential.Your privacy will be protected. Jessica Mascher will ask your permission before using your success story quote in marketing material. If you are a sleep client and have a psychiatric diagnoses or medications please disclose that, as this may influence sleep choices or sleep planning. If you are having challenges with your parenting partner, please let us know, as that could help Jessica Mascher serve you better. Jessica Macher will offer advice that is aligned with the most current American Academy of Pediatrics recommendations. If you make decisions that do not align with these AAP guidelines, we will note that choice in the parenting plan document/email and Jessica Mascher will help you create the safest, most effective plan based on those choices you feel are right for your family.

By signing below I am agreeing that I understand that Jessica Mascher is not a licensed psychotherapist or medical professional and that I am responsible for all my decisions regarding my child’s care. If remedies or nutritional changes are suggested, I agree that I am responsible for consulting my medical or nutritional care professional before implementing said changes. I hold harmless Jessica Mascher from any claims arising out of Jessica Mascher's advice and/or performance of the work of providing the above services.

• Most fees are set as “packages.” You will be provided services based on the package you have chosen.

- Invoices will be sent directly to your email via the Square App and must be paid prior to our first consultation. Payment may also be made in person at our first consultation if consultation is in person.

- Appointments can be scheduled via the Square Appointments site. Jessica will send you a link to this.

- Duration: Each meeting is up to 90 minutes and can take place virtually- by phone or video chat.

- Add-on 90 minute meetings are $100.

- Packages come with as many emails as listed. Each email counted is the email response you receive from Jessica Mascher, which answers your email. Emails will be answered within 48 hours but likely much sooner.

- If not tier 5, unlimited e-mail support can be added to any package for an additional, one-time fee of $200

- There is an additional $25 charge PER VISIT to those who wish to have consultation in home and live with 15 miles away from downtown Seattle.

- There is an additional $40 charge PER VISIT to those who wish to have consultation in home and live 15-30 miles away from downtown Seattle.

- Hands on support includes travel in cost and is available to those families who live within 15 miles of downtown Seattle.

- Refunds are not offered.

Cancellations:

❍ Give at least 12 hours of notice to re-schedule a call/meeting time.

Consultations that are missed without notice or rescheduled two times in a row with 12 hours or less notice will still be counted towards your package's included consultation.

I am interested in:

Tier 1 Package: One time, (up to) 90 minute Virtual consultation. 1 email support exchange. 1 introductory e-mail with helpful links to further sleep-related information. ($115)Tier 2 Package: 1 (up to) 90 minute Virtual Consultation with personalized written out plan e-mailed to you afterwards to refer back to. 3 email support support exchanges. 1 introductory e-mail with helpful links to further sleep-related information. ($175)Tier 3 Package: 2 (up to) 90 Minute Virtual Consultations, a personalized written out plan e-mailed to you after our first consultation to refer back to, and 4 email support exchanges.1 introductory e-mail with helpful links to further sleep-related information. ($260)Tier 4 Package (only available to families within 15 miles of downtown Seattle): 3 hours of hands-on support offered in one 3-hour shift, 2 (up to) 90 Minute Virtual Consultations, a personalized written out plan e-mailed to you after our first consultation to refer back to, and 4 email support exchanges.1 introductory e-mail with helpful links to further sleep-related information. ($530)Tier 5 Package (only available to families within 15 miles of downtown Seattle): 6 hours of hands-on support offered in two 3-hour shifts, 2 (up to) 90 Minute Virtual Consultations, a personalized written out plan e-mailed to you after our first consultation to refer back to, unlimited email support forever.1 introductory e-mail with helpful links to further sleep-related information. ($730)

Add- On Options

Additional (up to) 90 Minute zoom or Phone Consultation ($100)Additional (up to) 90 Minute Zoom or Phone Consultation with Written Plan Emailed Back to You ($130)Unlimited E-mail Support ($200)In- Home Meeting Travel Fee within 0-15 miles of downtown Seattle ($25)In-Home Meeting Trace Fee within 15-30 miles of downtown Seattle ($40)Additional observation/check-in Support (only available in-person to families within 15 miles of downtown Seattle). 3 hour minimum for in home visit. ($55/hour)

I agree to the terms and conditions listed above. I agree to pay the fee associated with my chosen package and any chosen add-ons either before or at our first consultation and understand that a refunds are not offered. I understand that Jessica Mascher will reach out to me within the next 48 hours to set up our first service.

Jessica Mascher LMT & Perinatal Services