Your Name
First Name
Last Name
Child's Name
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First Name
Last Name
Your child's birthday
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Email
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What is your child's current sleep schedule
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ex:
Wake 7am
Nap 1 9:30-11:00am
Nap 2 2:00pm-4:00pm
Bedtime 7:00
What does your child's bedtime routine look like?
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Describe your child's current sleeping arrangement
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Be as specific as possible.
Example: my child sleeps in a twin bed in a room shared with one sibling, nightlight, blackout curtains, white noise.
or: My baby sleeps in nursery in a crib with white noise machine, in a fleece sleep sack.
How many hours does your child sleep in a 24-hour period?
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Does your child use any props to fall asleep?
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Does your child use a pacifier?
Which developmental milestones has your child reached?
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Describe your child's personality
Describe your feelings about crying
What are your goals for this consultation?
Describe your most ideal results. Shoot for the moon and tell us what your hopes are!
Have you tried any other sleep programs or sleep training methods?
How did you hear about Mother Together?
Do you want to begin your consultation on a specific date? If not, leave today's date and we will begin working on a sleep pan right away. If you purchased support, your support begins on the date the plan is delivered.
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Name
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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 a Mother Together sleep consultant 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, Mother Together and its consultants do not assume responsibility for errors, omissions, or contrary interpretation of the subject matter within the consultation. Reliance on any advice given by Mother Together and its consultants 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 Mother Together either verbally, written or implied remains the property of Mother Together 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 Mother Together and its consultants is confidential. Any passing of any information to anyone is strictly forbidden and subject to international copyright laws.
First Name
Last Name
