Preliminary Questionnaire Unlimited Support Babies Plan

Your answers to the following questions will help me better customize your child's sleep plan. If you would like to revise your answers before submitting, please hit "save" and return to complete it when you're ready. Please allow two business days to receive your sleep plan. (Sleeping Well Consulting is open Monday through Friday, with the exception of U.S. public holidays). Thank you so much, and here are the questions:

Parent's Name *

First

Last

Email *

Phone

What is your child's name? *

What is your child's birthdate? *

How much does he/she weigh? *

Was your child premature? *

Did he/she have colic or reflux? *

Have there been any health issues or concerns? *

Is your child on any medication? *

Have you spoken to your doctor about your child’s sleep difficulties? *

What time does your child wake to start his/her day? *

What happens at this time? Are they given a bottle, breastfeed, start with solids, etc. *

What signals do you notice your child gives when he/she is tired? *

What time of day does the first nap usually occur and where does it take place? *

How do you get your child to sleep for this first nap? *

How long does this nap last? If nap length varies, please describe. *

What time of day does the second nap occur? *

How does your child fall asleep for this nap? *

How long does this nap last? If it varies, please describe. *

Is there a third or fourth nap during the day or early evening? *

How does your child fall asleep for these naps? *

What time do you start getting your son/daughter ready for bed? *

What do you do with your child when getting them ready for bed? (For example: bath, brush teeth, sing songs, read stories, play a game, etc.) *

What time does your child actually fall asleep at bedtime? *

How does your child fall asleep at this time? (Rocking, feeding, cuddling, etc.) *

Was there a time when your child slept well through the night, and napped well, and had no early morning wake-ups and then things changed? *

What are some ways you've tried to get your child to fall asleep? Which of those do you tend to use the most? *

How does your child react when she/he is placed in the crib, bassinet, co-sleeper or bed? (i.e. happy? reluctant? or usually asleep?) *

Is your child able to communicate when she/he is hungry, has a soiled diaper, or needs comfort? *

On a scale of 1-5, (with 1 being not very persistent and 5 being extremely persistent) how persistent would you say that your child is? *

	1	2	3	4	5
	1	2	3	4	5

On a scale of 1-5, (with 1 being not very adaptable and 5 being extremely adaptable) how adaptable would you say that your child is? *

	1	2	3	4	5
	1	2	3	4	5

On a scale of 1-5, (with 1 being not very easily frustrated and 5 being extremely easily frustrated) how easily frustrated would you say that your child is? *

	1	2	3	4	5
	1	2	3	4	5

On a scale of 1-5, (with 1 being not very easy-going and 5 being extremely easy-going) how easy-going would you say that your child is? *

	1	2	3	4	5
	1	2	3	4	5

Please describe your child's eating habits. Have you had struggles with your child's eating and feeding? If your child is eating solid foods, what kinds of foods does he/she like and dislike? *

What milestones has your child met? (rolling both directions, sitting up, pulling up on his/her own, standing, walking, etc.) *

What are your short term (one month) goals for your child's sleep? What are long term goals? *

In your perfect world, when would your child fall asleep for bedtime, wake for morning and nap (if still napping)? Where would your child sleep? *

Is there anything else you would like to share with me that you think I should know? *

That's all the questions, thank you! Next, please tick the box for your client agreement, and remit payment. I look forward to receiving this information from you so I can get started writing your customized sleep plan!

Sleeping Well Consulting Client Agreement (Unlimited Support Sleep Plan) *

This field is marked as required and has to be ticked to be submitted.

Please read over the following client agreement and tick the box above that you accept the terms and conditions of this agreement.

By ticking the box, you acknowledge that I will provide you with a plan that is as gentle as possible, and allows you to stay with your child, if preferred, but that crying can not be prevented if your child's emotional response to a change in his/her sleep process is to cry. I will provide you with options to soothe, comfort, reassure and support your child, but please understand that crying is a symptom of frustration, confusion, and often fatigue and as such may not be prevented.

YOUR COMMITMENT AS MY CLIENT:

Payment is due upon receipt of your invoice, and without it, I won’t be able to write your sleep plan.

Commit to the plan. It works! Have faith that what we’ve agreed upon will work and stick to it long enough to see the result.

If you don't follow ALL of the plan you can't expect to achieve full results.

I COMMIT TO YOU AS YOUR COACH:

To put your child first. Our entire plan will be created to benefit of your child. I will ask you to make changes and I will educate you on how your decisions and actions impact your child’s sleep.

Please understand that I can provide you with multiple options, but that if you don't want to do any of the steps required to initiate change that a refund will not be offered, as I have indeed provided you with my time and expert knowledge as promised.

To be available to you for our appointment(s). I avoid rescheduling calls because I know what it’s like to be anxious for support. In return, I hope that my clients will stick to our arrangements as well out of respect of the other families that I work with.

To be patient. I know you’re sleep deprived and you’re doing the best you can. I don’t judge any of your decisions up to this point, and I respect you for investing in your child’s sleep health.

To support you the best I can. Implementing change is hard! I’m here if you need to vent, cry or talk something through.

To abide by the follow-up guidelines that I’ve provided to you. We will mutually schedule our phone calls and I will reply to your emails or texts as soon as I can (often immediately!) but if anything, within 24 business hours.

Follow-Up Guidelines -- How The Support Part of Your Plan Works:

Your package includes four check-in calls to be used within 2 weeks of starting your sleep plan.
Your package includes unlimited emails and texting via WhatsApp, all to be used within two weeks of beginning your sleep plan. Email me: [email protected] with your questions and I will respond within 24 business hours.
If you don't receive a response within 24 business hours, please send a follow-up email.
Business hours are Monday through Friday, 8:00 a.m. to 5:00 p.m. (unless other arrangements have been made for bedtime, overnight or half-night consultations).
Sleeping Well Consulting is closed on all public holidays.

DISCLAIMER

My Services Are Not Medical Advice. The advice you receive from me is for informational purposes only and is intended for use with common early childhood sleep issues that are wholly unrelated to medical conditions. The early childhood sleep issues that I work with are related to behavioral conditions related to habits learned over time. My advice is NOT intended to be a substitute for medical advice or treatment. Always seek the advice of your doctor or other qualified health practitioner regarding any matters that may require medical attention or diagnosis, and before following the advice and using the
techniques described herein.

EXCLUSION/LIMITATION OF LIABILITY
Kim Rogers does not make any representations or warranties, express or implied, regarding consulting services provided. Kim Roger’s liability (if any) is limited to the consulting fee paid by you to Kim Rogers and in no event will Kim Rogers be liable to you for any other claim, losses or damages.

By ticking the box, "I have read and understood the commitments outlined above and by signing below agree to the terms of this agreement".

By agreeing to this release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use tick the box.

PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.

Single Item

Price: $ 449.00

Stripe Credit Card *

Card

Name on Card