Pickles And Ice Cream – Sleep Baby Consulting Sleep Intake Form - Pickles And Ice Cream

Today's Date:*

Child's Name:*

First

Last

Sleep Consultation Options:*

Sleep consultations are detailed on website www.sleepandbabyconsult.com

Child's Age*

Please use adjusted age for children born before 37 weeks

Child's Sex:*

Home Address:*

Street Address

City

State / Province / Region

ZIP / Postal Code

Country

This is required for scheduling and in-home consultations

Current Time Zone*

Eastern EST
Mountain MST
Central CST
Pacific CST
Central Europe
UK
Asian Pacific
Alaskan Time Zone
Hawaiian Time Zone

Parent #1:*

First

Last

Parent #1 Profession & Work Hours:

Parent #1 Email:*

Parent #2:*

First

Last

write N/A if no 2nd parent

Parent #2 Profession & Work Hours:*

Write N/A if no 2nd parent/caregiver

Parent #2 Email:*

Nanny or Caregiver Name/Names

Please list grandparents, nanny or other caregivers that will be helping with the sleep
Please write N/A if just you will be guiding the sleep

Daycare Name: School Drop Off & Pick-Up Time:*

Phone Number For Consultation & Text Support:*

Erin’s Information:

Phone: (314) 489-2644

FaceTime or Skype (only if choosing to do FaceTime or Skype)

Erin’s Information:
Skype: erinmeckfessel (st. louis)

Face Time: erin@sleepandbabyconsult.com

Current Sleep Behaviors and Issues:

Sleep Issues:*

Please mark all that apply

Does Your Child Nap?*

Does Your Child Stil Nap?
What time/times:
For how long:

What time is bedtime?*

Sleep Location:*

Mark All That Apply

Does your child wake in the middle of the night?*

Breast Feeding/Bottles/Milk*

Check All That Apply

Daily Breast-Milk/Formula/Milk Intake:*

Daily Intake:

Does your child use a pacifier?*

Does your child snore?*

Please List Any Medical Issues or Concerns:

Please list any medical or other behavioral issues:

Medical Issue Influencing Sleep:*

Has your child been sick or vaccinated within the last week?*

Are you aware of Back To Sleep Campaign?*

This year, the Safe to Sleep® campaign celebrates its 20th anniversary! In the 2 decades since the program began, the U.S. rate of SIDS has dropped by more than 50%.
Learn more about the Safe to Sleep® campaign and SHARE with the parents you know. #SafeToSleep http://1.usa.gov/ZN6Ext

Parents and caregivers can reduce the risk of Sudden infant death syndrome (SIDS) and other sleep-related causes of infant death, such as accidental suffocation. Find out how to create a safe infant sleep environment. #SafeToSleep http://1.usa.gov/1sMq9Aq

Sudden infant death syndrome (SIDS) is the leading cause of death among babies 1 month to 1 year old.
Find out what you can do to reduce your baby’s risk of SIDS and other sleep-related causes of infant death, such as accidental suffocation. SHARE to let others know. #SafeToSleep http://1.usa.gov/1yhdKpS
There are many things parents and caregivers can do to help baby sleep safely. How many can you name?
For a complete list of safe sleep recommendations, visit the Safe to Sleep® website. #SafeToSleep http://1.usa.gov/1sMq9Aq

Sleep & Feed Log

Please feel free to attached any documented feeding or sleep schedule if you wish.

Additonal Details or Concerns:

Please write any additional information, questions or concerns regarding your child’s sleep

How did you find out about Pickles & Ice Cream Sleep Consulting?*

Please list the name and referral type:
pediatrician?
friend?
family member?
school?
online blog?
facebook?
other social media?
Other?

Confirmation

Please look for a confirmation text from 314-489-2644 or email from erin@sleepandbabyconsult.com with 72 hours. Please make sure to add erin@sleepandbabyconsulation to avoid confirmation email going to spam. Filling out this sleep intake form DOES NOT confirm a consultation but is required before booking a consultation. Once an agreed upon consultation package, date and time is established, the client will be required to make a deposit or payment in full to confirm the consultation.

Erin Meckfessel

FSI Certified Sleep Consultant & IBPA Baby Planner

{314} 489.2644 | Email me

Current Sleep Behaviors and Issues:

Confirmation

FOLLOW US: