Name * First Name Last Name Baby's First and Last Name Baby's Age What email will you be using for your consultation(s) Does your baby have any medical issues we show know about? (Example oral lip/tongue ties, GI issues (reflux), allergies). What does your baby's bedtime routine look like (skip if you don't have one) What is your current feeding choice? Exclusively breastfed Breastfed with bottle feeding as well Formula Breakmilk and Formula Combo What type of sleep outfit does your baby sleep in? (Example: footed pajamas, swaddle, transitional sleep suit, sleep sack, etc.) What does your baby's sleep arrangement look like? (Please be specific, example: baby sleeps in a crib, bassinet, their own room, with sibling(s), bed sharing, bedside sleeper, etc.) How many total hours does your baby sleep in a 24-hour period? (Naps + Nighttime Sleep) Does your baby use any sleep props to fall asleep? or back to sleep? Select all that apply* Nursing to sleep Bottle to sleep Rocking to sleep Bouncing, swaying, or any other movement My baby does not use any props to fall asleep at naptime, bedtime or during the night. Other Which personality type best describes your baby. You may select more than one. Quiet, mellow, laid back, doesn't mind change. Cranky, fussy, rarely in a happy mood. Strong willed, stubborn, resists change. Other What developmental milestones (if any) has your baby accomplished? Select all that apply* None yet (newborn stage) Holding head up when placed on belly Rolling onto side Rolling onto back Rolling from back to belly Sitting, but can't lay back down Sitting, and knows how to lay back down Crawling Standing, but can't sit back down Standing, and knows how to sit back down Walking All of the above milestones Which statement best describes how you feel about crying?* Please note - Sleep Purely Baby never uses the "cry it out method", or advocates leaving a crying baby. We use gentle and healthy sleep foundations/ I don't mind hearing crying I don't mind hearing some crying I cannot hear any crying at all Other Please provide in detail, any additional information that will help me understand what's going on with your baby'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 add additional information by emailing me. Terms & Conditions BY SIGNING BELOW, YOU AGREE TO THE FOLLOWING TERMS AND CONDITIONS: MEDICAL DISCLAIMER: The information/advice provided during this consultation is not medical advice. You are not establishing a medical professional/patient relationship. The advice is for informational purposes only and is intended for use with healthy children with common sleep issues that are unrelated to medical conditions. The information provided is not intended nor is implied to be a substitute for professional medical advice. Always seek the advice of your physician with any questions you may have regarding a medical condition or the health and welfare of your baby. PEDIATRICIAN APPROVAL: You agree to consult with and get approval from your pediatrician before following the advice or using the techniques offered during this consultation. LEGAL NOTICE: In no event will Sleep Purely Baby, LLC. be liable to you for any claims, losses, injury or damages as a result of reliance on the information provided. All though all attempts have been made to verify the information provided is accurate, Violet Giannone does not assume responsibility for errors, omissions, or contrary interpretation of the subject matter within the consultation. Reliance on any advice given by Sleep Purely Baby, LLC. is solely at your own risk. REFUND POLICY: Due to the amount of time, effort, and commitment provided within a consultation, refunds are not possible once this form is submitted. COPYRIGHT NOTICE: The information provided within the consultation may not be reproduced, republished, or transmitted in any form or by any means mechanical or electronic, including photocopying and recording, or by any information storage and retrieval system, without permission. All information supplied by Sleep Purely Baby, LLC. either verbally, written or implied remains the property of Sleep Purely Baby, LLC. at all times. Written permission is required to reproduce, record, publish or advise verbally any details of the provided sleep plan, E-guides, charts, notes, advice offered or consultation transcript or summary in any format whatsoever. This includes but is not limited to any details published on any blogs, forums, or similar boards. Any information supplied by Sleep Purely Baby, LLC. is confidential. Any passing of any information to anyone is strictly forbidden and subject to international copyright laws. I have read and agree to the terms and condtions as stated I do not agree Signature By typing your name below, you have read and accepted this document. Thank you!
