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Book Your Consultation

Complete the intake form and I’ll get back to you with a customised sleep plan.

Your full name *

Baby’s name *

Baby’s age *

Baby’s DOB *

Current daytime sleep schedule

Does your baby use a pacifier to sleep?

Yes, and I often have to reinsert it Yes, but it’s not a prop No

What email address did you use for payment?*

What email address will you use for the consultation?*

Today's date

How many hours does your baby sleep in 24 hrs?*

What does your baby's bedtime routine look like? (Leave blank if none)

What type of sleep outfit does your baby sleep in?

Describe your baby's sleeping arrangement

Does your baby use any sleep props?* (select all that apply)

Nursing to sleep Bottle to sleep Rocking to sleep Bouncing / swaying / movement None Other

How is your baby currently getting nutrition?* (select all that apply)

Breastfeeding Formula Solids Other

Does your baby receive any nighttime feedings?*

Yes No

Which personality type best describes your baby? (select all that apply)

Quiet / mellow Cranky / fussy Clingy / anxious Strong-willed / stubborn Happy / playful Other

Have you tried any other methods or programs?

What developmental milestones has your baby accomplished?*

None yet Holding head up Rolling onto side Rolling belly ➜ back Rolling back ➜ belly Sitting, can't lay down Sitting & can lay down Crawling Standing, can't sit Standing & can sit Walking All of the above Other

Which statement best describes how you feel about crying?*

I don't mind hearing crying I don't mind hearing some crying I cannot hear any crying at all Other

Please provide additional information or questions

How did you hear about Thyme4Sleep?*

Did a friend refer you? If yes, enter their name

Desired consultation start date (leave blank for earliest)

Signature* (type your full name)

Anything else I should know?

I have read and agree to the terms and conditions.

Thyme4Sleep

Pediatric Sleep Coaching by Georgia Miller

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Email: georgia@thyme4sleep.com

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