Caregiver 1 Name (First & Last)
Occupation
Caregiver 2 Name (First & Last)
Occupation
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
Phone
(###)
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Preferred Contact Method
How did you hear about Green House Doula?
Any preferred pronouns or family language that I can support?
Who lives in your household (e.g., siblings, grandparents, etc.)?
How would you describe your parenting style? (Any specific approaches, experts, or philosophies you align with?)
Tell me about your support system (who supports you emotionally or practically).
How do you care for yourself right now (habits, hobbies, rituals)?
How would you describe your own sleep? (Bedtime routine, average bedtime, how you feel about sleep in general)
Any recent bloodwork (thyroid, iron, ferritin, vitamin D)?
Are you currently taking any medications or supplements that may affect sleep?
Daily stress level (1–10)? What’s contributing most to your stress?
Any personal or partner mental health history or current support being received?
Any family history of sleep disorders (apnea, insomnia, snoring, etc.)?
Child’s Name & Age
Date of Birth (Was your child born early, on time, or late?)
Birth Weight
Any siblings? (Names & ages)
Any history of hospitalizations or ongoing medical concerns?
Are you working with any specialists, therapists, or other providers to support your child? (e.g., OT, PT, lactation consultant, craniosacral therapist, etc — list names and roles if known)
Any past or current medical conditions or concerns? (e.g., Colic, reflux, eczema, asthma, congestion, allergies, oral ties, torticollis, plagiocephaly, etc.)
Any suspected or diagnosed developmental or behavioral conditions? (e.g., Sensory Processing Disorder (SPD), ADHD, Autism, etc.)
Is your child taking any medications or supplements (especially near bedtime)?
Does your child breathe through their mouth, snore, breathe noisily, or wake with dry mouth/sore throat?
Has your child been evaluated or treated for oral ties, sleep-disordered breathing, or similar concerns? Please share details.
How is your child growing? Are they following their growth curve, or has there been any change? Please share any details or input from your pediatrician.
Is your child meeting their developmental milestones so far? Are there any specific milestones they’re currently working on, or anything you’ve been wondering about, even if you haven’t raised it with your pediatrician?
Any of the following? (Check all that apply):
Is your child breastfed, formula-fed, or both?
What are your long-term feeding goals (if any)?
Have you worked with a lactation consultant? Who and when?
Check any feeding challenges you've noticed:
Other feeding challenges (please describe)
Do you have any concerns about nutrition or dietary intake?
Any known or suspected food allergies, sensitivities, or restrictions in your child — or family history?
Is your child eating solids? If yes, when did they start, and are you using purees, baby-led weaning, or both?
What does a typical day of food look like (include meals, snacks/drinks/treats)?
If over 12 months, any of the following? (Check all that apply):
Do you notice any sensory sensitivities in your child? (e.g., avoids hair or teeth brushing, dislikes getting dressed, prefers rough play or strong bouncing, sensitive to sounds, lights, textures, or smells.)
How does your child like to be soothed or calmed? (Include anything that helps, such as rocking, deep pressure hugs, gentle bouncing, swaddling, or other comforting strategies.)
Does your child have strong preferences or aversions around movement? (For example, do they seek out spinning, jumping, or prefer very calm activities?)
How does your child respond to changes in routine or environment? (e.g., easily upset, needs extra time to adjust, or seems flexible.)
Does your child have difficulty with transitions or shifts between activities?
Does your child become easily overwhelmed or reactive in social or noisy environments?
How do you manage your own stress and regulation, especially around your child’s sleep and routines? What helps you stay calm and present during challenging moments?
Any current stressors, transitions, or big changes in the home? (e.g., illness, travel, arguments, childcare changes, moves, new baby, etc.)
How do you spend time together? What kinds of activities do you enjoy?
How much outdoor time does your child get daily?
How much time do they spend freely moving (not in a container, seat, or carrier)?
Is your child in childcare? If yes, how do you feel about it? How is your child adapting?
How do you respond to tears or frustrations during the day?
If over 9 months, what boundaries (if any) have you started setting?
Do you use any type of discipline? If yes, please describe.
Are you feeling any pressure about your parenting choices (from family, friends, etc.)?
What is your child’s typical morning wake-up time? Does this vary day-to-day?
Nap/rest time(s) and how long they generally last:
Describe the nap routine (if any).
Describe the bedtime routine (if any).
Time you begin bedtime routine and time they fall asleep.
How long does it usually take your child to fall asleep at nap time and bedtime?
What parts of your current sleep routines do you enjoy or appreciate? What feels easeful, meaningful, or especially supportive right now?
What does your child wear to sleep? (Include fabric, tags, tightness, footed/non-footed, etc.)
Sleep supports used (check all that apply):
Other sleep supports used? Please describe.
Describe the Lighting at night? (Pitch black? Nightlight? Hallway light?
If a nightlight is used, what color is it?
Sleep location(s) (check all that apply):
Combination of the above sleep locations or other. Please describe.
If multiple sleep locations, when/how does your child move during the night?
Room temperature in the day? At night?
Any external noise in the sleep environment? (TV, street noise, creaky floors, etc.)
Child's typical sleep positions (e.g., on stomach, bum in the air, arms under tummy, on back, on side, etc.):
When your child wakes at night, how do they fall back asleep? (Independently or with help? Please describe what you do.)
Best non-feeding strategies for soothing nighttime upset?
Do you change diapers overnight?
Have you tried any sleep training approaches? If yes: What method, any success, and did you work with a consultant (please name)?
Any upcoming changes that could impact sleep? (e.g., travel, new baby, move, childcare changes, etc.)
What do you believe sleep should look like for a child this age?
Briefly describe your current sleep concerns or struggles? Is this a new issue? When did it begin?
What are your top two priorities for your child right now?
What are your top two priorities for yourself?
What are your biggest concerns about doing sleep work together?
How would you describe your current level of need?
Other. Please Describe.
Best days/times to connect? Any upcoming scheduling conflicts?
Anything else you’d like to share?