Intake Form

Thank you for your intake form submission.

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Name:*

Your email address:*

Your phone number:*

Referred by:

Your child(ren)'s name(s) and age(s):

What is your chief complaint?:
(e.g.: sleep, eating, lactation, management, caregiver planning)

Have you ever engaged in any speciality services/consultations for your child? If so, what for?

Does your child have any medical conditions or diagnoses? If so, what?

Have there been any recent changes in your home life? If so, when?
(such as job relocations, family loses, caregiver changes?)

What are your greatest strengths as a parent?

What are you greatest weaknesses as a parent?

What are your goals for your family?

Describe your schedule, including parents, siblings, caregivers, and housekeepers.

List any classes or group activities your child participates in. Can these appointments be changed if needed?

How often does your family travel?

What are the best elements of your routine?

What are the worst elements of your routine?

What percentage of the day is your child cared for by:

	Day	Night	Weekend
Mother
Father
Daycare
Caregiver (Paid)
Family Members
Other

What is the longest your child has slept at night in the last three months?

What methods do you use to get your child to sleep?
Pacifier, bottle, breast, for example?

Does your child have a transitional object?
A special blanket or teddy, for example?

How long does it take to get your child to sleep? What methods do you use when?

What is the longest you have heard your baby cry?

Where does your child sleep?
Your bed, his/her own bed, crib, shared room with other siblings?

When your child wakes at night, how long does it take for him/her to get back to sleep?

Describe your morning and bedtime routines. How long does this take?

How would you describe your child's appetite? Does s/he eat regularly?

Does your child eat solid foods?

Does your child nap during the day? If so, for how long?

All information submitted is considered confidential and privileged. Filling out the intake form allows me to evaluate your situation prior to the initial phone consultation. Some clients prefer to cover this information during the initial phone consult itself – Sarah Petrie.