Infant Sleep Questionnaire Let's get to know each other! I look forward to learning more about your child. Registration Date * MM DD YYYY Parent 1 * First Name Last Name Email * Phone * (###) ### #### Parent 2 First Name Last Name Email Phone (###) ### #### Child * First Name Last Name Child's Date of Birth MM DD YYYY Child's Age * Gender * Male Female Non-binary Prefer not to say Address Address 1 Address 2 City State/Province Zip/Postal Code Country Primary Care Person: Please explain your household and who cares for the child most often and if your child goes to a daycare or with a nanny. * Please rate your current stress level * Not at all stressed Slightly stressed Somewhat stressed Very stressed Is your child currently on any medication? * Yes No Please list the medication the child is on. Have you worked with a sleep consultant before? * Yes No What are your goals for your child? Please explain if you have dealt with any challenges that you think have caused sleep disruptions/habit formation. How motivated are you to start the training？ * Not at all motivated Slightly motivated Somewhat motivated Highly motivated If you have a specific questions or concerns, please list them here. Thank you for filling out the infant questionnaire! You are one step closer to a good night’s sleep.