Sleepy Newborn Client Intake - Natasa - Precious Moments Babeez

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Where the Heart Is

Thank you for booking a Sleepy Newborn Package with Natasa!

In order to ensure that I have a better picture of your current situation please
fill out as much detail as you can in the intake form below. I understand this may be very
vague but I just need an idea of what your child’s current habits and routines
are. This forms needs to be filled and sent back to us at least 24 hours prior to our
appointment or your appointment will be CANCELLED without refund. Please DO NOT fill out this form too far in advance because things may change with your child and will not give me a clear picture of what is currently happening.

Sleepy Babeez Intake - Natasa

* Indicates required field

Parents Name *

First

Last

Second Parents Name *

First

Last

Email *

Telephone number you can be reached at for the consultation *

Child's Name *

First

Last

Childs Age *

Child's current weight *

Gestation of child at birth (full term/preemie-please indicate how many weeks) *

IN POINT FORM, please tell me a bit about your labor and birth. Was your labor quick? Did baby spend alot of time in the birth canal? Where forceps or suction used? *

Where is your child currently sleeping? *

Co-sleeping in bed with parent Sleeping in their own crib but in parents room Parent sleeping in childs room Child sleeping in crib in his own room Child sleeping in bed in his own room Other

Please indicate how your child is currently being fed *

Exclusively Breastfeeding Breastfeeding and Bottle Combo Bottle Feeding Exclusively Breastfeeding plus solids Breastfeeding/Bottle feeding Combo plus Solids Bottle feeding plus solids Solids Only

Please inicate the length of time it takes to feed your child *

If your child is eating solids, please explain a usual meal quanity and what foods it consists of *

Does your child have any issues with eating? Please explain ex food aversions etc *

Does your child use a pacifier? *

Yes No Sometimes

Please indicate any health concerns for baby or mother (ex. postpartum depression or medical concerns) *

Please tell us if you have tried any prior methods of sleep training or nurturing. Explain the method you have tried. *

Please indicate what level of sleep issues you feel your child has below *

My child sleeps well but would like to get them in their own bed My child sleeps well overnight but not for naps My child sleeps well for naps but not overnight My child does not sleep at all

Who currently puts your child to sleep? Check all that apply *

Mommy Daddy Grandparents Nanny Other

Do you suspect your child is suffering from any of the following? Please check all that apply *

Gas Colic Reflux Teething Constipation Nightmares Night Terrors Seperation Anxiety Eczema Other

Do you have any classes, appointments or activites you have to accomodate for during training *

Please tell us about your current living situation (ex. 3 bedroom house, condo, 1 bedroom apartment, etc) *

Please tell me how you currently get your child to sleep ex rocking, feeding, singing, etc *

Is your child currently attending daycare? If not yet, please indicate if he will be and the estimated start date *

Please include a detailed description of your childs morning routine from 7am-12 noon (Include meal & sleep times, activites, etc) *

Please include a detailed description of your childs afternoon routine from 1pm-8pm (Include meal & sleep times, activites, etc) *

Please include a detailed description of your childs overnight routine from 9pm-7am (Include meal & sleep times, activites, etc) *

Do you have any other children? Please tell me their age and sleep habits *

Please indicate any other issues or concerns you think we should know *

Are there any other topics you would like discussed in this consult? ex. Starting solids, offering a bottle on occassion, etc *

What would be your ideal bedtime and wake time? be specific ex. Bed at 8am, wake at 7am *

What city do you live in? *

What is the main goal you would like acheived through this program, be specific? *

We would love to have a picture of you and your child so we can put a face to the voice during our time together. This will not be used for any other purposes. This is not manatory. *

Max file size: 20MB

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