Sleep Intake Form
CLIENT INFORMATION:
Parent Name
Age
Occupation
*Current or previous to parent
Address
City/State
Zip
Phone
*Please include the best number
to reach you for follow ups
Email
Parent Name
Age
Occupation
*Current or previous to parent
Address
City/State
Zip
Phone
*Please include the best number
to reach you for follow ups
Email
OTHER MEMBERS OF HOUSEHOLD:
Place asterisk (*) next to name of child whose sleep habits you are seeking help for
Name
Date of Birth
Age
How did you hear about me, or who referred you?
The Cradle Company │1359 N Hill Avenue, Pasadena, CA 91104│ www.thecradlecompany.com
Page 1
CLIENT HISTORY:
1. Child’s Name:
2. Child’s Date of Birth:
PRENATAL:
*Please circle best answer
a. Was this a planned pregnancy?
□No
b. Any problems during the pregnancy? □No
c. Delivery/Labor:
Vaginal
C-Section
d. Any complications?
□No
3. Was your child born full term?
No
a. If no, at how many weeks was s/he born?
4. Any medical problems for newborn at birth?
□No
□Yes
□Yes (please describe)
VBAC
□Yes (please describe)
Yes
□Yes (please describe)
The Cradle Company │1359 N Hill Avenue, Pasadena, CA 91104│ www.thecradlecompany.com
Page 2
5. These questions are regarding the Mother:
a. Are you able to sleep at night when your child is sleeping?
b. How is your appetite?
c. Are you having any troubling/scary thoughts?
The Cradle Company │1359 N Hill Avenue, Pasadena, CA 91104│ www.thecradlecompany.com
Page 3
DOCTOR INFORMATION:
Pediatrician Name
Practice Name
Phone
Street
City / State / Zip
OB/GYN Name
Practice Name
Phone
Street
City / State / Zip
d. Has your pediatrician ruled out any medical problems that may be causing
or contributing to your child’s sleep problems?
□Yes
□No (please describe)
e. Would they state that your child “should” be able to sleep through the
night given their age, weight, and medical health?
□Yes
□No (please describe)
The Cradle Company │1359 N Hill Avenue, Pasadena, CA 91104│ www.thecradlecompany.com
Page 4
DEVELOPMENT AND HEALTH HISTORY:
1. Approximately when did your child reach the following milestones (where
applicable):
a. Rollover
b. Sit Up
c. Scooting/Army Crawl
d. Crawling
e. Standing
f. Walking
g. 1st Words
2. Feeding
a. Is your child:
□Formula-fed
□Breastfed
□Both
□Neither/Weaned
b. Has your baby started solids?
□No
□Yes, at age
3. Are they using a:
□bottle
□cup
□both
4. What is your child’s current weight?
a. What percentile are they in?
5. Does your child:
a. Suck thumb/fingers?
b. Use a pacifier?
c. Have a security object (i.e. blanket, stuffed toy)?
animal
□No
□No
No
□Yes
□Yes
Yes
6. Any past or current medical or developmental problems?
□No
□Yes (please describe)
The Cradle Company │1359 N Hill Avenue, Pasadena, CA 91104│ www.thecradlecompany.com
Page 5
7. Does your child wet the bed (if potty trained) during the night?
□No
□Yes
N/A
If yes, how often?
/week
If yes, is there a pattern to the bedwetting? Please describe.
8. Does he/she sleepwalk? □No
If yes, how often and at what time?
□Yes
9.
Does your child snore?
□No □Yes
10.
Does your child mouth breathe?
□No □Yes
11.
Does your child fall out of bed?
□No □Yes
12.
Is your child a restless sleeper?
□No □Yes
13.
Does your child sweat while sleeping?
□No □Yes
14.
Does (or did) your child have reflux problems or colic? □No
If so, how long did it last? When was it resolved? What helped?
15.
Does your child have any of the following?
□Allergies
□Asthma
□Frequent Ear Infections
□Frequent or constant stuffy nose
□Yes
The Cradle Company │1359 N Hill Avenue, Pasadena, CA 91104│ www.thecradlecompany.com
Page 6
16.
Does your child have nightmares?
How often and at what time?
□No □Yes
SCHEDULE:
1. Are your child’s sleeping disturbances new or ongoing since infancy?
2. What techniques have you tried up to this point to address your child’s
sleep problem?
3. Answer the following questions (a-g) ONLY if they have not been
answered in the above “Schedule” question:
a. Is your child in a crib or bed?
The Cradle Company │1359 N Hill Avenue, Pasadena, CA 91104│ www.thecradlecompany.com
Page 7
b. Where does your child sleep?
c. If your child sleeps in your bed, does your spouse see this as a problem or
something they want to change? □No □Yes
N/A
Do you see this as a problem or something you want to change?
□No □Yes
d. Does the sleeping location change during the evening/night? For example,
does your child fall asleep in your bed and then have to be moved to his/her
own bed? Or, does he/she fall asleep in his/her own bed and then come into
your bed during the night?
e. Does he/she share a bedroom with a parent, brother, sister or someone
else?
□No □Yes
f. Does he/she stay in his crib/bed without trying to get out?
□No □Yes
g. Does he/she get out of bed during the night?
□ No □Yes
If yes, where does he/she go?
The Cradle Company │1359 N Hill Avenue, Pasadena, CA 91104│ www.thecradlecompany.com
Page 8
4. How do you get him/her to sleep? Describe the routine.
5. How long before bedtime do you start this routine?
6. Is there a fixed bedtime? Is so what time is it?
7. If you have other children, do they go to bed at the same time?
□No □Yes
The Cradle Company │1359 N Hill Avenue, Pasadena, CA 91104│ www.thecradlecompany.com
Page 9
8. Does your child feel sleepy during the day but not take a nap?
□No □Yes
9.
Is your child afraid of the dark? □No □Yes
10.
Is either parent fearful of the dark? □No □Yes
11.
Do you leave a light on for your child, or the bedroom door open? □No □Yes
12.
Is your child distressed when s/he is left alone in his/her crib/bed? □No □Yes
If so, what do you do?
13.
Does your child head bang or rock his/her body? □No □Yes
14.
Do you stay with your child while he/she goes to sleep, or do you leave him/her
to fall asleep on his own? If you stay, how long do you stay for?
15.
How long does it take your child to go to sleep?
The Cradle Company │1359 N Hill Avenue, Pasadena, CA 91104│ www.thecradlecompany.com
Page 9
16.
Is there a pattern to your child’s night awakenings? For example,
does he/she wake at approximately the same times?
17.
How would you describe your child’s temperament?
18.
How does your child handle time by him/herself?
19. Are there rituals or certain things that your child does to self- soothe?
The Cradle Company │1359 N Hill Avenue, Pasadena, CA 91104│ www.thecradlecompany.com
Page 10
20.
Do your other children currently have (or previously have)
problems with sleep? If yes, what did you do to address it?
21.
Any recent changes in your home life? (e.g. relocation, work, family losses,
caregiver changes) If so, when?
The Cradle Company │1359 N Hill Avenue, Pasadena, CA 91104│ www.thecradlecompany.com
Page 11
22.
23.
24.
What are your greatest challenges and strengths as a parent?
List any activities that your child participates in. Can these
appointments be changed if necessary?
How often does your family travel?
The Cradle Company │1359 N Hill Avenue, Pasadena, CA 91104│ www.thecradlecompany.com
Page 12
25.
What percentage of the day is your child cared for by:
Day
Night
Weekends
Mother
Father
Daycare
Caregiver (paid)
Family Member
26.
What is the longest your child has slept in the last three months?
27.
What is the longest you have heard your baby cry?
28.
How would you describe your child’s appetite and current eating
routine?
The Cradle Company │1359 N Hill Avenue, Pasadena, CA 91104│ www.thecradlecompany.com
Page 13
29.
Are both parents in support of and willing to participate in helping your child
learn to sleep through the night? □No □Yes
30.
What is the ultimate outcome you and your spouse would like to see with
regard to your child’s sleep habits? Please be specific. For example: What would
you like your child’s sleep schedule and sleep habits to look like at the conclusion
of treatment
The Cradle Company │1359 N Hill Avenue, Pasadena, CA 91104│ www.thecradlecompany.com
Page 14
The Cradle Company │1359 N Hill Avenue, Pasadena, CA 91104│ www.thecradlecompany.com
Page 15