Toddler, Preschool, & School-Age Sleep Questionnaire

I’d like to ask you to take a few minutes to answer some questions about your child’s sleep habits and more before we have our consultation. This will help me prepare for our meeting and will let us make the best use of our time together. Please note, that some questions may not apply to your family and if that is the case, feel free to skip over those.

Please include as much information as possible; this will help me learn about your child and family and all the factors that could affect sleep. Please return this as quickly as possible so I can begin working on your child’s sleep program.

Thank you for putting your trust in me to help your child to develop healthy sleep habits.

Before we begin, please share with me why you have chosen to seek help with your child's sleep. What issues are you currently facing

Email*

Who referred you?

How did you find Sleep at Last?

What size t-shirt do you wear? (you'll thank me later 😉 )

Small

Medium

Large

Parents' Full Names:

Mailing Address:

What time zone are you in?

Who lives in home with the child? Includes names and ages of siblings.

Medical Questions

Child's full name (and nickname if preferred).

Child's date of birth.

Have there been any health issues or concerns? (this may include anything from developmental delays to weight gain issues to medical diagnoses). If yes, please describe.

Is your child on any medication or supplements (vitamins, melatonin, etc)? If yes, please list and describe for what purpose.

Does your child snore or is he/she a heavy mouth breather?

Does your child wet the bed?

Is your child potty trained or in the process of potty training?

If yes to the above potty training question, please indicate what stage your child is at with the process:

Any other details you'd like to share with me regarding potty training?

How you spoken to your doctor about your child's sleep difficulties? If so, what did the doctor say?

Who is your child's pediatrician? May I contact him/her regarding our time together?

Dietary Questions

Does your child have any food allergies or sensitivities?

How would you describe your child’s eating habits? (picky eater, healthy appetite, only eats same 5 things..)

How much juice, milk, or soda does your child consume in a day?

What would an average day of food consumption look like?

Does your child have any snacks right before bed? If so, what?

Personality and Behavioral Questions

How would you describe your child's temperament and personality?

Are there any behaviors issues/concerns other than sleep?

Do you currently use any kind of positive reinforcement or behavior modeling tools in your home for your child? Please describe.

How do you handle disciplining your child? How does your child respond?

When your child is misbehaving, what have you found to be the most effective way to help redirect your child? How does your child respond?

Does your child respond differently to different caretakers in relation to either instruction or challenging behaviors? If so, please describe.

How does your child respond to stress?

How does your child handle transitions from one activity to another?

Activities and Interests Questions

What other activities or sports does your child do in the week?

What does your take interest in or like to play with? (For example, certain activities, specific toys, or TV character)

Does your child regularly watch TV or use other sorts of electronic devices? If so, when and where does this generally happen?

During Phase 1, we are going to be working on creating and enforcing boundaries around your child’s challenging Daytime behaviors. We are looking to start with “easier” behaviors, which will gain you confidence as your child starts to respect your boundaries. You can build up to more challenging behaviors, which will become easier as your child begins respecting you and your boundaries. Together, we will decide on what behaviors we will start with. Some examples include: Brushing teeth, putting on shoes, getting dressed, holding hands while outside/in public, throwing food, eating a meal, getting in the car....etc.

Please list out some of the day time behaviors that you are struggling with. We will use these ideas to choose our first day time behaviors to start working on.

Please share any other behavioral details here that may be helpful.

Sleep Questions

Was there a time when your child did sleep well, and things changed?

Where does your child sleep? Do he/she share a room with anyone? If no, any plans of this happening?

Does your child use a pacifier of lovey? If so, please explain.

Does your child use a clock (such as the Hatch or an Okay to Wake Clock) and/or a nightlight? If yes, please describe.

Does your child sleep with his/her bedroom door open or shut? Please explain.

Morning

What time does your child start the day?

Does your child wake naturally around the same time every day or does he/she use and alarm/require you to wake up? Is there a struggle to get up and get going in the morning on a regular basis?

What is your child's mood upon waking?

What is a typical morning like in your household?

Daytime Schedule

Is your child cared for by someone other than you?

Yes

If yes to the above question, who cares for your child during the day? What day(s) is your child cared for by someone other than parents?

What time do you drop off and pick up your child?

How long is the drive to get there?

What is the sleep environment like when not at home?

Do you see any potential concerns with making changes to your child's sleep with their caregiver?

Will there be any changes to your child's caregivers/locations in the near future?

Naps

Does your child take a daytime nap? If so, what time is the nap, how long is the nap, and where does your child nap?

Does your child ever skip a nap or take an extra nap during the day? Please explain.

Where does the nap take place?

How do you get your child to fall asleep for the nap?

Bedtime

What time do you start getting your child ready for bed at night?

What is your child's bedtime routine (for example, bath, teeth, PJs, books, into bed)? Please list all the steps, in order.

During the bedtime routine, is your child protesting, refusing to do steps, or having trouble transitioning through the routine?

What is the scenario when your child is falling asleep? Be as specific as possible.

What time does your child actually fall asleep at bedtime?

Where does your child sleep? Is it the same location all night? If not, please explain.

Does your child share a room with anyone? Do you have any plans for this to happen?

What does a "best case scenario" look like and how often does this happen?

What does a "worst case scenario" look like and how often does this happen?

Describe the typical or average night.

When asked about his/her struggles with sleep, what answer does your child give about the issues they are having? Does he/she verbalize the problem/stress/concerns they have about sleep? Are they able to identify possible causes and/or solutions for the problems?

Scheduling Questions

Does your child/family have any evening obligations (such as clubs, sports, school pickups, classes, etc) that would interfere with your child's naptime, or ability to keep a consistent bedtime routine and bedtime? If so, please share details on your schedule.

Do you eat dinner together as a family and, if so, what time?

Is there a specific schedule that you need for your child (specific bedtime, morning wake up, or nap time?) If not, please indicate a preferred wake time or bedtime, so I can create an appropriate schedule for your child.