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 (select all that apply):
How did you hear about Green House Doula?
Any preferred pronouns or family language I can support?
Who lives in your household? (e.g., siblings, grandparents, others)
Tell me about your support system (who supports you emotionally or practically).
How do you care for yourself right now? (Habits, hobbies, rituals, frequency)
How would you describe your own sleep? (Bedtime routine, average bedtime, overall feelings about sleep)
Any recent bloodwork or relevant health info for you? (e.g., thyroid, iron, ferritin, vitamin D)
Are you currently taking any medications or supplements that may affect your sleep or energy?
On a scale of 1–10, how would you rate your daily stress level? What contributes most to your stress?
Any personal or partner mental health history or current support being received?
Any family history of sleep disorders? (e.g., apnea, insomnia, snoring, etc.)
Child's Name and Age:
Date of Birth:
Any siblings? (Names & ages)
Any history of hospitalizations or ongoing medical concerns?
Are you working with any specialists, therapists, or providers supporting your child? (e.g., OT, PT, speech therapist, feeding therapist, behavioral specialist, etc. — please include names and roles if known)
Any past or current medical or developmental concerns, differences, or specific needs? (e.g., asthma, eczema, allergies, oral ties, sensory processing differences, behavioral or developmental diagnoses, etc.)
Is your child currently taking any medications or supplements? If so, please list, especially those taken near bedtime.
Does your child breathe through their mouth, sleep with their mouth open, snore, have noisy breathing, or wake with a dry mouth or sore throat?
Has your child been evaluated or treated for oral ties, sleep-disordered breathing, or other related concerns? Please share details.
How is your child’s growth? Are they following their pediatrician’s growth curve? Any concerns or recent changes?
Is your child meeting developmental milestones? Are there any areas you’re currently watching or have concerns about?
Is your child still nursing at all? If yes, please share any relevant details.
Do you have any concerns about your child’s nutrition or dietary intake?
Any known or suspected food allergies, sensitivities, or dietary restrictions?
What does a typical day of food look like for your child? (Include meals, snacks, drinks, and treats)
Does your child consume caffeine or sugary foods? If yes, when and how often?
What time does your child typically eat breakfast, lunch, and dinner? Do they have a bedtime snack?
Is your child fully toilet trained? If not, what stage are they in?
Does your child wake during the night to use the toilet? If so, how often?
Does your child wear pull-ups or diapers during the day or night?
Any recent changes in toileting habits or concerns (e.g., accidents, bedwetting)?
Does your child express any anxieties or fears around using the toilet, especially at night?
What does your child’s bedtime toileting routine look like?
How independent is your child with hygiene routines (e.g., teeth brushing, dressing)?
Who cares for your child during the day? (e.g., daycare, school, grandparents, nanny) How often and for how long?
How physically active is your child throughout the day? Please describe typical activity level and types of activities.
What are your child’s favorite indoor and outdoor activities?
How much time does your child spend outside daily? Have you noticed any changes in mood or sleep related to outdoor time?
Does your child participate in any sports, extracurriculars, or structured exercise?
How much screen time does your child have each day? What types of screens, and when are they used?
What time of day does your child seem most energetic? When do they seem more tired or calm?
Do you notice any energy fluctuations, such as bursts of energy late in the evening?
Do you notice any sensory sensitivities or preferences in your child? (For example: sensitivity or aversion to light, sounds, textures, clothing tags, certain smells, or tactile sensations.)
How does your child typically respond to common sensory experiences such as teeth brushing, hair washing, getting dressed, or temperature changes?
Does your child have particular preferences or aversions related to movement? (For example: seeking activities like spinning, jumping, swinging, or preferring calm, still play.)
How does your child respond to changes in routine or environment? (For example: easily upset, needing extra time to adjust, or generally flexible.)
Does your child become easily overwhelmed or reactive in busy, noisy, or social settings?
Are there specific times of day, activities, or transitions when your child seems more sensitive or dysregulated?
Does your child have any routines, objects, or rituals that help them feel safe, calm, or regulated?
How do you support your child’s regulation during stressful or overwhelming moments? What strategies or soothing activities have been most helpful?
How do you manage your own stress and regulation, particularly around your child’s sleep and daily routines?
What is your child’s typical wake-up time? Does this vary day-to-day?
Does your child nap or have a quiet/rest period during the day? Please describe usual timing and length.
What time does your child typically go to bed?
Describe your child’s bedtime routine (steps, length, who is involved).
Does your child fall asleep independently or need assistance?
How long does it usually take your child to fall asleep for naps (if applicable) and at bedtime?
Does your child wake during the night? If yes, how often and what do they typically do or need?
Does your child use any comfort items at sleep? (e.g., blanket, stuffed animal, white noise)
Does your child have any particular sleep associations? (e.g., needing a specific object, song, presence of parent)
Does your child experience any of the following? (Check all that apply)
Other. Please describe.
Does your child take a long time to fully wake or seem tired/unrefreshed in the morning?
Does your child appear sleepy during the day?
Where does your child sleep? (Own bed/room, shares room, co-sleeping, etc.)
Describe the sleep environment (noise level, room temperature, lighting, bedding preferences).
How dark is the sleep environment?
If a nightlight is used, what color is the light?
How does your child typically handle transitions between activities or routines?
How does your child respond to separations from you or their primary caregiver?
How does your child usually express big emotions or stress? What helps soothe or calm them?
How does your child ask for extra reassurance, closeness, or comfort? When does this most often happen? (e.g., bedtime, after daycare)
Does your child have any specific fears or anxieties around bedtime or sleep?
How would you describe your parenting style? Are there specific approaches, philosophies, or experts you follow?
How were you parented as a child? Are there any experiences that shape your current approach?
What is your approach to discipline and setting boundaries?
How do you manage bedtime resistance, if it occurs?
How do you communicate upcoming changes to your child? Which strategies have worked well?
Does your child respond well to changes in routine, or do they find them challenging?
Are there any recent or upcoming changes in the household that might impact your child’s sleep or sleep work? (e.g., new sibling, move, travel)
Have you tried any specific sleep strategies before? What were they, and how did they work?
Please 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?
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?