Carla Rocha - Postpartum Doula - Oakland

1. Your full name:

2. Your child's name

3. Your child's age

4. Email used for payment

5. Email you wish to use for consultation (if different)

6. What is your child's current daytime sleep schedule (if any)?

7. What does your child's bedtime routine look like?

8. What does your child wear at bedtime?

9. What does your child's sleeping arrangement look like? Please be specific:

10. Please describe, in as much detail as you can, the environment in which your child sleeps.

11. How many hours does your child sleep in a 24-hour period?

12. What are your childcare arrangements?

Home with a parent

Home with a nanny

Daycare

Other

(please specify below)

13. Does your child use any sleep props to fall asleep? You may select more than one:

Nursing to sleep

Bottle to sleep

Rocking to sleep

Bouncing, swaying or any other movement

My child doesn't use any props to fall asleep at bedtime or during the night

14. Does your child use a pacifier to sleep?

Yes, and I often have to reinsert it

Yes, but it's not a sleep prop - my child doesn't mind if it falls out

No, my child doesn't use a pacifier

15. Is your child breastfed or bottle fed? If your child is weaned from the breast or bottle, please just write N/A

16. Which describes your child's personality? You may select more than one:

Quiet, mellow, laid-back, doesn't mind change

Cranky, fussy, rarely in a happy mood

Clingy, anxious, often experiences separation anxiety

Strong-willed, stubborn, resists change

Happy, playful, usually in great spirits

17. Have you tried any other methods or programs to get your child to sleep better?

18. Which developmental milestones (if any) has your child accomplished? Select all that apply:

19. Which statement best describes how you feel about crying?

I don't mind hearing crying

I don't mind hearing some crying

I cannot stand to hear any crying

20. Please provide, in detail, any additional information that will help me understand what's going on with your child's sleep troubles. If you have specific questions, you can include them here, too. If you forget to add something, no worries; you can always send me an email later.

21. Do you want to start the consultation on a particular date? If not, enter today's date and I will begin working on a sleep plan right away. Keep in mind, once the sleep plan is sent, your consultation begins on that date.

How did you hear about me?

Family Information Questionnaire

Contact us any time

Attending San Francisco; East Bay; South Bay; North Bay; Peninsula

Menu