Miniconsult questionnaire

Please complete this form and submit it 48 hours prior to our call. The more detailed your responses are, the better. Thank you!

Parent's name

First Name

Last Name

Child's name

First Name

Last Name

Child's date of birth

YYYY

When did you begin having problems again with your child's sleep?

If your child is sleeping in a bed (even if it is a toddler bed or a crib with the front rail removed), at what age did he/she move into a bed?

What does your bedtime routine look like these days?

Where is your child currently sleeping at night?

Does he care who puts him/her to bed? Is there a preference for one parent over the other?

What happens when your child wakes in the middle of the night?

Has your child had any medical treatments, surgeries or occupational therapy interventions since our previous work together?

If yes, please explain including details of the diagnosis, treatment, dates of treatment and outcome.

Do you think of your child as a restless sleeper?

Yes

Is your child potty trained?

Yes

If your child is potty trained, are they in underwear at night?

Yes

Any other information that I should know about your child's latest sleep troubles?