Erin Leetzow Sleep Consulting Free Website Intake Form

Your full name *
Your child's name *
child's age (add adjusted age if baby was born premature) *
Your preferred email for contact *
Your location (state and time zone) *
Anything medical that should be known about *
Reflux, tongue/lip ties, etc.
What is your child's current daytime sleep schedule (if any)? *
What does your child's bedtime routine look like? Skip if you don't have one. *
What type of sleep outfit does your child sleep in? *
What does your child's sleeping arrangement look like? Please be specific. *
How many hours does your child sleep in a 24hr period. (Naps+ Night time sleep)? *
Does your child use a pacifier to sleep. *

Yes, and I often have to reinsert it. Yes, but it's not a prop. My child doesn't mind or cry for it when it falls out. No my child does not use a pacifier.
Does your child use any sleep props to fall asleep or back to sleep during the night? Select all that apply. *

Nursing to sleep Bottle to sleep Rocking to sleep Bouncing, swaying, or any other movement My child does not use any props to fall asleep at bedtime or during the night
Which personality type best describes your child. You may select more than one. *

Quiet, mellow, laid back, doesn't mind change. Cranky, fussy, rarely in a happy mood. Clingy, anxious, often experiences separation anxiety. Strong willed, stubborn, resists change. Happy, playful, usually in great spirits.
Have you tried any other methods or programs? *
What developmental milestones (if any) has your child accomplished? Select all that apply *

None yet Holding head up when placed on belly Rolling onto side Rolling from belly to back Rolling from back to belly Sitting, but can't lay back down Sitting, and knows how to lay back down Crawling Standing, but can't sit back down Standing, and knows how to sit back down Walking All of the above milestones
Is your child with a caregiver (nanny, daycare, etc.) during the day? If so how many days a week? Are they willing to work with us and make changes? *
Which statement best describes how you feel about crying? *

I don't mind some crying I prefer a quicker method I prefer less tears even if it means the method takes longer
Since tears are your child's form of communication, do you understand that I cannot promise no crying? I work with clients to minimize the tears. *

Yes No
Are you and any household members committed to following a plan? *

Yes No
What changes would you like to see in your child's sleep? *
Please provide in detail, any additional information that will help me understand what's going on with your child's sleep troubles. If you have specific questions you can include them here too. If you forget to add something, you can always add additional information by emailing me. *
How did you hear about Erin Leetzow Sleep Consulting? Did a past client of mine refer you? If yes, please tell me their name.
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