Parent (1) Name
*
First Name
Last Name
Occupation
Parent (2) Name (if applicable)
First Name
Last Name
Occupation
Location or Address (if applicable)
*
Email
*
Phone
*
(###)
###
####
Preferred Method of Contact (select all that apply)
*
How did you hear about Green House Doula?
*
Who currently lives in your household?
Does your family have any preferred pronouns, terms, or language that I can support?
How would you describe your personal parenting style, and are there any specific approaches, philosophies, or experts that you follow or feel aligned with?
Describe your support systems (people in your life who provide you with support).
Tell me about your own sleep hygiene. Do you have a nighttime routine? What do you do before you fall asleep? What time do you go to bed? How do you feel about sleep?
How do you practice self-care (activities, hobbies, rituals, how often, etc)?
Child's Name and Age
Date of Birth. Were they late, early or on time?
Child's birth weight and current weight.
Are there any other siblings or children in the home? If yes, please provide their name(s) and age(s).
Tell me about your child and their temperament—who they are, their likes and dislikes, their best qualities, and any personality challenges you’ve noticed.
Is your child meeting their milestones? Are there any specific ones they’re currently working on? Please describe.
Are there any health concerns, chronic conditions, illnesses, or allergies I should know about? Have you discussed them with your baby’s pediatrician?
Are you currently working with, or have you previously worked with, any other specialists or practitioners besides your child’s pediatrician? If yes, please list their names and title. (e.g., IBCLC/Lactation, Sleep Specialist, Chiropractor, Craniosacral Therapist, Occupational Therapist, Physical Therapist, Naturopath, etc.)
Are there any medical conditions or factors that may affect your child's sleep, such as oral ties, apnea, asthma, eczema, allergies, reflux, digestive concerns, frequent ear infections, colic, sensory sensitivities, or restless legs?
Has your child been diagnosed with any developmental or behavioral differences, such as ADHD, sensory processing differences, Autism, anxiety, speech or language delays, or learning disabilities?
Is your child currently taking any medications or supplements? If so, please list them and indicate if any are taken close to bedtime.
Does your child tend to sleep with their mouth open or breathe through their mouth during the day? Do they snore or have noisy breathing at night, and do they wake up with a dry mouth or sore throat?
Has your child ever been evaluated or treated for oral ties, sleep-disordered breathing, or other sleep-related or developmental concerns? If yes, who performed the evaluation and what were their findings?
Please check all that apply:
Please describe any sensory preferences or differences you’ve noticed in your child (e.g., sensitivity to light, touch, taste, smell, sounds, or textures). Do they seek strong movement, like aggressive bouncing or rocking? Do they enjoy rough-and-tumble play, or do they avoid certain types of touch or motion?
Does your baby drink breastmilk, formula, or both?
If you are breast or bottle feeding, have you noticed:
If "other", please describe.
Is your baby eating solid foods? If so, at what age did they start, and are you offering purees or using baby-led weaning? Please describe their typical daily nutritional intake.
Do you have any concerns about feeding you would like to share?
Are you, or another adult who is close to your baby ill, exceptionally busy, or going through an emotionally difficult time?
Is there anything else that may be going on in your house that might be affecting your baby? Parent arguments, new nanny, new baby, a job change, a move, daycare?
Please describe the amount of time you spend with your baby and the types of activities you do together.
How much time does your baby spend playing outdoors?
How much time does your baby get per day to move freely and explore (not in a stroller, seat, or other baby container)?
Is your baby in any type of childcare (daycare, nanny, etc)? If they yes, how you feeling about the childcare and how is your little one adapting?
Are you feeling any pressure about your parenting choices from people around you? Extended family?
What time does your child typically wake up each morning? Is this a consistent wake time or does it fluctuate?
Does your child have a nap, rest, or quiet period during the day? Describe the routine.
What time do you typically start your child’s bedtime routine, and what time do they fall asleep? Please describe the routine.
On average, how long does it take for your child to fall asleep at both nap time and bedtime?
What does your baby wear to sleep? Please describe the fabric, fit (tight or loose), footed or non-footed, presence of tags, and any other details.
What sleep aids do you use for your child? Please select all that apply.
If "other", please describe.
Please check all that apply:
If your baby sleeps in more than one location, please give me an idea of when your baby/child changes locations throughout the night.
What is the exact room temperature during the day? At night?
How is the lighting in your baby’s sleep environment? Is it pitch black, dim, or is there light from a nightlight or hallway? If a nightlight is used, what color is it?
In what position does your baby sleep? (On stomach, hands under tummy, bum up in the air, on side, on back, etc?
If your baby wakes at night, do they fall back asleep independently or do they need support from you? If they need parental help, what is it that you need to do - please describe in detail.
When your baby is upset at night, what do you find is the best way to calm them other than feeding? Please describe.
Do you change your baby's diapers at any point after putting them down to bed?
Have you ever done any sleep training? If yes, please describe IN DETAIL - the method, whether you saw any success, if you used a sleep consultant (it is helpful if you provide a name so that I have a better idea of the approach used).
What are your expectations of what sleep should look like for a child of this age?
How would you describe your current struggle or concerns with sleep? Is this a new issue? When did it begin?
Do you have any particular questions or concerns that you'd like to discuss on our call?
Is there any additional information that you feel would be helpful to share?