About This Template
Complete this detailed intake form before your sleep consultation to give your consultant a full picture of your child's sleep history.
Fill in each field below with your specific information. Fields marked with an asterisk (*) are required. Replace all bracketed text with your actual details and remove the brackets.
How to Use This Template
- Print this page or copy the template into a word processor.
- Replace each bracketed field with your actual information. Remove the brackets.
- Remove sections that do not apply. Write N/A for required fields that do not apply.
- Review the completed document for accuracy. Check every field twice.
- Have someone else review it before final submission.
- Keep a copy for your records.
Sleep Consultation Intake Details
Complete each field below with information specific to your sleep consultation intake situation.
Sleep Consultation Intake Form
First name or initials for privacy.
Used to determine age-appropriate sleep expectations.
The date this log entry covers.
The time you put your child down for the night. Example: 7:15 PM.
When your child actually fell asleep (may differ from bedtime).
Times and durations of each waking. Example: '11:30 PM (5 min), 3:00 AM (15 min, fed).'
When your child woke for the day.
Start and end time for each nap. Example: '9:30-10:15 AM (45 min), 1:00-2:30 PM (90 min).'
Add up all nap durations in hours and minutes.
From fell-asleep time to morning wake time minus night waking durations.
Anything unusual: teething, illness, travel, skipped nap, new food, etc.
The person you are caring for.
Your full legal name.
Spouse, child, parent, hired caregiver, etc.
The main medical conditions requiring care.
Describe daily assistance required: bathing, feeding, medication management, mobility, etc.
Name, relationship, and phone number.
Contact Information
Your identification and contact details for this sleep consultation intake document.
As it appears on your government-issued ID.
MM/DD/YYYY format.
Street, city, state, ZIP code.
Best number to reach you during business hours.
Optional but recommended for faster correspondence.
Signature
I certify that the information provided in this document is true and correct to the best of my knowledge.
Important Notes
- Do not submit this template with bracketed placeholder text still in place.
- Verify all information against your source documents before submitting.
- Keep the original completed document and at least two copies.
- Check whether the receiving office has specific formatting requirements.