Toddler & School-Age Child Intake Form Full Name Email* Street Address City, State Zip Spouse / Partners Full Name Spouse / Partners Phone Number Spouse / Partners Email Address Your Toddler's / School-Age Child's Full Name Your toddler / school-age child's date of birth? Tell me about your toddler's / school-age child's wonderful personality, likes & dislikes. Are there any medical conditions to be aware of for your toddler?? Where does your toddler / school-age child sleep? In Their Own Room In Our Room Crib Toddler Bed Full-size Bed In Bed with Us What time does your toddler wake for the day? Is your child in preschool / daycare / elementary school Daycare Pre-School Elementary School Total screen-time in the day? None Less than 1 hour 1-3 hours Too Much Does your child still nap? Yes No Depends on the Day If yes, what time is that nap? What time is bedtime kickoff? What happens then? Do any of the following apply to your toddler or school-age child? Ask for Sitting or Laying Until Asleep Overnight Wakings to Come into Your Bed Nightmares or Night Terrors Stalling at Bedtime Anxiety Parent Preference {Mom or Dad Only} Early Morning Wakings What time are they actually falling asleep? What happens during the night, BEST and WORST case scenarios with your child? Was there a time when your child slept well? What is your IDEAL day, as a goal for our time together? Is there anything else you would like to share with me? Who referred you to Tiny Transitions for support? Submit
