Sleep Coaching Questionnaire I'd like to ask you to take some time to answer some questions about your little one's sleep habits, which will allow me to learn more about their current struggles and specially what I can do to support you on your journey to good sleep! Full Name Email* Contact Number Your Spouse's Name? Your Spouse's email if he / she needs access to the daily sleep log too? Child's Full Name Are there Siblings? Age? How is his/her sleep? Where Does Your Child Sleep? Crib/cot Bassinet Bouncer / Yao lan Pack-N-Play Bed In their own room In our room With sibling Tell me about your child's wonderful personality, likes & dislikes, Are there any medical condition to be aware of? Does Your Child Use Any of the Following? Pacifier Night light White noise machine Black out curtain Sleep training clock How Do You Dress Your Child to Sleep? Does your child rely on any of the following to fall asleep? Rocking or Bouncing Feeding - Nursing or Bottle Co-Sleeping / Laying with Them Pat Other Total Screen-Time in the Day? None 15-30 min 1-3 hours Too Much What time does your child wake for the day? What signals does your child give you when they are ready for sleep? Is your child under the care of a nanny or helper or daycare? No, home with me Nanny or Caregiver Daycare What time is your child napping? How do they settle? What is the duration? What time is bedtime kickoff? What happens then? What time is your child actually falling asleep? What happens during the night, BEST and WORST case scenarios? Was there a time when your child slept well and then things changed? What is your child's daily eating schedule? How much or how long they take to finish the food? What is your IDEAL day like wake up time and bedtime, as a goal for our time together? What programs or books about pediatric sleep have you explored? Is there anything else you would like to share with me? Who referred you to UpChild? UpChild community (0-6yo): we provide Sleep consultation, Baby signs course and Potty learning. Three areas feed off one another and are very important for the child and the whole family in the early years. They can tell you their needs before they c Baby Signs course (tell me more) Craniosacral therapy No, thank you Submit
