FAMILY HISTORY FORM

SLEEP SUPPORT FOR CHILDREN WITH SPECIAL NEEDS

In order to ensure that our time together is effective, please fill this out as completely as you can, with as much detail as possible. If you have already answered a question in a previous part of this form, please say "see previous answer" or something similar ... you do not need to answer things twice! Also, if some of the questions do not pertain to your child, please write N/A as necessary.

Parent #1 Name

First Name

Last Name

Parent #1 Age

Parent #1 Occupation

Parent #1 Address

Parent #2 Name

First Name

Last Name

Parent #2 Age

Parent #2 Occupation

Parent #2 Address

Best Phone Number to call for follow-up calls

(###)

###

####

Best Email

How did you hear about me / who referred you to me?

Are you interested in receiving my newsletter?

Child's Name

First Name

Last Name

Date of Birth

YYYY

Please share any other children's names and ages

Was this a planned pregnancy?

Did you experience any problems throughout the pregnancy?

If you did experience problems, please describe:

Any complications during labor/delivery?

If yes, please describe.

How many weeks was your child when born?

Were there any medical problems for your child at birth (if yes, please describe)?

Mom - are you having any troubling, or scary, thoughts?

Pediatrician Name / Address / Phone

At what age did your child roll over?

At what age did your child sit up?

At what age did your child scoot / army crawl?

At what age did your child stand up?

At what age did your child walk?

At what age did your child use his/her first words?

Are there any past/current developmental needs or diagnoses that I need to know about?

What is your child's current weight?

What percentile is your child in for weight?

Please outline your current typical day and night time schedule with your child in detail from waking up and through the night. Please include meal times as well. Also include times that are particularly difficult for your child, and what you do to try to help your child.

What does nighttime sleep look like for your child? What time does he/she go to bed, and wake up? Are there any wakeups overnight? If so, what happens at that time? What is the usual bedtime routine?

Is your child distressed when left alone in crib/bed? If so, what does s/he do, and what do you do?

Does your child bang his/her head or rock his/her body?

Does your child have nightmares? If so, how often, and around what time?

Does your child wet the bed (if potty trained) during the night? If yes, how often, and is there a pattern to the bedwetting?

Does your child sleepwalk? If yes, how often, and what time?

Does your child snore?

Does your child fall out of bed?

How would you describe your child's temperament?

How does your child usually handle time to himself/herself?

Do you notice certain things your child does to self-soothe?

If your child has a diagnosis, when was he/she diagnosed, and how did this diagnosis come about (were you concerned, was someone else in your family/life concerned?)

What therapies, if any, does your child receive?

What therapy(ies) if any, did your child have previously?

What are 2-3 of your child's favorite things to do?

How do you know when your child needs / wants something?

How often are you confused by your child's behavior, and unsure of what he/she wants or needs?

What is the ultimate outcome you and your spouse would like to see with regard to your child’s sleep? Please be specific, for example: What would you like your child’s sleep to look like at the conclusion of treatment?

What have you tried that has worked in regards to sleep before?

What have you tried that has NOT worked in regards to sleep before? Please describe what you tried, and what didn't work about it.

Please describe your parenting philosophy in about 5 sentences or less. What principles guide your day-to-day parenting lives? What do you strive for in your parenting? What do you try to avoid in your parenting?

Is there anything else you would like to share that you have not already shared?

Checkbox

Please check the boxes next to each statement to signify your acknowledgement of the details of our work together. These items are required before we begin working together.

I acknowledge I will forfeit my time if I am more than 20 minutes late to my consultation call without communicating via email (katie@behavioristnextdoor.com)

I acknowledge my payment is non-refundable unless otherwise specified via email or form.

I acknowledge I will keep a sleep log, be on time for all follow-up calls, and communicate as needed throughout the coaching process.

I acknowledge sleep coaching advice is NOT medical advice. You are solely responsible for discussing any possible medical conditions with your child’s physician or other health professional. You understand that you assume primary responsibility for the health of your child and, to the extent permitted by law, you will not hold me or my practice responsible for any outcomes resulting from complications that are outside of my control.

I acknowledge that the Behaviorist Next Door (BND) does not accept insurance. I may submit my invoices to my insurance company but BND cannot guarantee reimbursement for fees or for expenses I may incur for the coaching sessions.

This form reflects the entire understanding between us and may only be changed in writing signed by both of us. If a court decides any of the terms are unenforceable, we agree that these terms will be severable from the agreement and all other terms of our agreement will remain in effect. By checking all of these boxes, I acknowledge that I understand and agree with all of the information herein.