Self-Care

Permission Slip for Self-Care

This is Your Permission Slip for Self-Care By Samantha Graham, MS LAC/Sleep Consultant (Glendale, Arizona) For the mom who just found her watch in the diaper genie; the one who is reheating cold coffee for the fourth time today; the one who broke down crying on the phone with the pediatrician because she could…

Name
First Last
Other Parents Name
Email
Phone
Which Sleep Consultant Are You Working With?*
Child's Name*
Childs Current Age
Was your child born prematurely?
- Yes
- No
Child's Birth Weight
Child's Current Weight
Please describe what your child sleeps in
i.e. sleeping bags, swaddles, blankets, pajamas, etc)? and where (family bed, co-sleeper, own crib, parent's bedroom, own bedroom
Does your child have any sleep props such as a pacifier, hammock, or comfort toy/lovie?
Please describe your child's sleep environment.
Is the room brightly lit, or dark? Lots of toys or very plain?
What does your child eat/drink over an average 24 hours?
Please specify amounts and content
Do you work outside the home?
- Yes
- No
If yes, who looks after your child and how do they get your child to sleep and when?
Does your child nap?
- Yes
- No
Does your child snore?
- Yes
- No
How do you settle your child for a nap?
How do you settle your child to sleep at night and what time is bedtime?
If your child wakes at night how do you settle them back to sleep and how often do they wake?
What have you already tried to do to solve your child's sleep issue, if anything? How did this go?
Does your child have any medical problems, like sickness or allergies?
Please briefly describe your parenting style:
Would you describe yourself as quite flexible or do you prefer a routine? Do you feed on demand or on a schedule? When your child wakes in the night or in the middle of a nap do you let him/her settle alone for a period of time or do you immediately go in to comfort him/her?
Do you have preschool, school, work or other regular commitments?
Please specify the times and days you have to leave the house and when you are back if you do have these commitments.
Would you prefer a strict schedule with the same wake up time, nap time, bedtime each day, or a flexible solution depending on what time your child wakes up?
Has your child gone through any major developmental milestones recently?
For example: Rolling over, crawling, sitting up, standing up, walking, eating solids, talking etc
Please describe in detail exactly what the sleep problem is that you're experiencing and what you would like to change.
How did you hear about A to Z Sleep Solutions?*

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