Newborn & Infant Intake Form Full Name Email* Street Address City, State Zip Spouse / Partners Full Name Spouse / Partners Email Address Spouse / Partners Phone Number Child's Name Child's Date of Birth Are there Siblings? Age? Where Does Your Child Sleep? Crib Bassinet Pack-n-Play Bed In their own room In our room With a sibling Tell me about your child's wonderful personality, likes & dislikes. Are there any medical conditions to be aware of? Does Your Child Use Any of the Following? Pacifier Night Light Sound Machine Room Darkening Shade / Curtains OK to Wake 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 Other Total Screen-Time in the Day? None Less than 1 hour 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 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 for how long are they eating? What is your IDEAL day, 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 Tiny Transitions? Submit
