Nest Care | Consultation Questionnaire

YOUR DETAILS
Full name
First Last
Email
Mobile
Address
House number / Street name Address Line 2 Suburb State / Territory Post Code Country

CHILDREN'S DETAILS
How many children in this consultation for?*
- One
- Two
Child 1
First Name*
Gender*
Date of Birth*
Date Format: DD slash MM slash YYYY
Age
Current Weight (In kilograms)*
Child 2
First Name*
Gender*
Date of Birth*
Date Format: DD slash MM slash YYYY
Age
Current Weight (In Kilograms)*
What is your relationship to these children?*
Have you/they previously worked with a sleep/maternity consultant or parenting/sleep support service?*
- Yes
- No
Who/where and was it helpful?*

REASON FOR CONSULTATION
What would you like help with? What strategies have you tried?
Child 1*
Child 2*

BIRTH HISTORY
In order to get a snapshot of your child, please let us know of any significant birth history.
Child 1: Gestational age at birth?*
Type of birth*
Birth Weight (In kilograms)*
Discharge date*
Child 2: Gestational age at birth?*
Type of birth*
Birth Weight (In kilograms)*
Discharge date*
Any medical interventions required after birth?
Child 1*
Child 2*

MEDICAL HISTORY/DETAILS
Have there been any previous or current medical conditions or concerns?
Child 1*
Child 2*
Is your child on any medication?
Is your child on any medication?*
- Yes
- No
What medication(s)?
Child 1*
Child 2*
Are there any known or family history of allergies?
Child 1*
Child 2*

SLEEP SETTLING
Sleep settling is how your child goes to sleep after a period of being awake e.g after playing.
Child 1: How do you currently put the child to sleep?
During the day*
At night?*
Child 2: How do you currently put the child to sleep?
During the day*
At night?*
How long do you leave them awake for before attempting/putting down for a nap?
Child 1*
Child 2*
SLEEP RESETTLING
Sleep resettling is how you resettle your child when they wake but should still be napping/sleeping.
If they wake and start to cry during sleep time, how long do you wait before going to them?
Child 1*
Child 2*
What happens during the night? (Best and worst case scenarios!)
Child 1*
Child 2*

DIARY/CURRENT ROUTINE
What time do they start and end the day?
Child 1*
Child 2*
Is this an ideal wake up/bedtime?
Child 1*
- Yes
- No
Child 2*
- Yes
- No
What is the ideal wake up/bedtime time?
Child 1*
Child 2*
What does your child’s typical day look like? What happened yesterday? Please provide a diary noting what happened yesterday - naps/sleeps, (when, where and how), along with how often/much they’ve eaten and for how long they’ve played.
Child 1*
Child 2*

GOALS
Please describe what good sleep/settling habits would look like to you, e.g. what room, what bed and how you would like your little one to sleep. What ways would you prefer to settle them? Do you want them to self-settle?
Child 1*
Child 2*
What type of parenting philosophy do you follow or wish to follow when it comes to sleep and crying?
*
- Attachment style (I don’t like/want my baby to cry at all)
- Authoritative style (I don’t mind a little crying if it leads to a positive outcome)
- Authoritarian style (I am quite strict and don’t mind any length of crying)
Aside from sleeping/settling better, what other goals do you hope to achieve at the end of our time working together?
Is there anything else you’d like to share that you think we should know before we talk?
Name
This field is for validation purposes and should be left unchanged.

Step 1 of 12

YOUR DETAILS

CHILDREN'S DETAILS

Child 1

Child 2

REASON FOR CONSULTATION

What would you like help with? What strategies have you tried?

BIRTH HISTORY

Any medical interventions required after birth?

MEDICAL HISTORY/DETAILS

Have there been any previous or current medical conditions or concerns?

Is your child on any medication?

What medication(s)?

Are there any known or family history of allergies?

FEEDING DETAILS

How many milk feeds do they have per day (24hrs)

What type of milk are they drinking? (Tick all that apply)

Is your child drinking milk using a bottle?

What type of bottle do they use?

Is your child having any solid foods/meals?

Please list meals/foods offered

PLAY / AWAKE PERIODS

On average how many naps do they have a day?

What is the longest they can stay awake for before napping/sleeping?

What is the shortest they can stay awake for before napping/sleeping?

Can your child (tick all that apply)

Do they have screen time? e.g. TV/iPad

How many hours a day?

SLEEP ENVIRONMENT & HABITS

Do they sleep mostly in a bassinette, cot, bed or other?

In what room do they mostly sleep?

Do you have any plans to transition your child to a new bed/room/space within the next six months?

SLEEP TOOLS

Do they use a dummy?

How long do you want to use it for?

Do you use music or white noise at sleep times?

Is the room light/dark or pitch black for most sleep times?

Do you have any mobiles above the cot?

Do they sleep with a special toy or comforter?

SLEEP SETTLING

Child 1: How do you currently put the child to sleep?

Child 2: How do you currently put the child to sleep?

How long do you leave them awake for before attempting/putting down for a nap?

SLEEP RESETTLING

If they wake and start to cry during sleep time, how long do you wait before going to them?

What happens during the night? (Best and worst case scenarios!)

DIARY/CURRENT ROUTINE

What time do they start and end the day?

Is this an ideal wake up/bedtime?

What is the ideal wake up/bedtime time?

What does your child’s typical day look like? What happened yesterday? Please provide a diary noting what happened yesterday - naps/sleeps, (when, where and how), along with how often/much they’ve eaten and for how long they’ve played.

GOALS

Please describe what good sleep/settling habits would look like to you, e.g. what room, what bed and how you would like your little one to sleep. What ways would you prefer to settle them? Do you want them to self-settle?

What type of parenting philosophy do you follow or wish to follow when it comes to sleep and crying?