Client Intake Please fill out this form so I can get to know your child better. Step 1 of 2 50% Name First Last Email* PhoneChild's Name* Gender* Boy Girl Gender Neutral Child's Age* Please enter in weeks to age 16 Weeks. Then in months up to age 12 months. In years following age one.What is child's current daytime sleep schedule? (if any). Mark none if not on Schedule.Example: Wakeup 7am Nap #1 11am-12pm Nap #2 3pm-4pm Bedtime 8pmWhat does your child's bedtime routine look like. Mark none if you don't have a routine*Example: Bath, put on PJ's and sleep sack. Then read or book, Nurse or bottle, then rock to sleep.What type of sleepwear does your child sleep in?*Example: Footed pajamas and Halo swaddle. Please be specific of what brand swaddle.What does your child's sleeping arrangement look like? Please be specific*Baby sleeps in own room and crib, no siblings in the room. Or, baby sleeps in a bassinet (brand) in parent's room on Mom's side of the bed.How many hours does your child sleep in a 24 hour period? Naps and Nightime Sleep*Example: 11.5-13 hoursDoes your child use a pacifier?* Yes, I often have to reinsert it Yes, but my child doesn't mind or cry for it when it falls out. No, my child doesn't use a pacifier Does your child use any sleep props to fall asleep? Or, back to sleep during the night? Select all that apply.* Nursing to sleep Bottle to sleep Rocking to sleep Bouncing, swaying or other movement Other Other sleep props to fall asleep? Which personality best describes your child?* Quiet, mellow, laid back, doesn't mind change Cranky, fussy, rarely in a happy mood Clingy, anxious, often experiences separation anxiety Strong willed, stubborn, often resists change Happy, playful, usually in good spirits Other Have you tried any other methods or programs?*What developmental milestones (if any) has your child accomplished?* None yet Holding head up when placed on tummy Rolling onto side Rolling from tummy to back Rolling from back to tummy Sitting, but can't lay back down Sitting, but knows how to lay back down Other Select all that applyOther development milestones your child has accomplished? 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.*How did you hear about Sleep Baby Sleep?*Do you want to start the consultation on a particular date? If not, leave today's date and I will begin working on a sleep plan right away. *Keep in mind that once the sleep plan is sent, your consultation begins from that date.* DD slash MM slash YYYY Consent* I agree to the privacy policy.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 Jillian Silva 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, Jillian Silva does not assume responsibility for errors, omissions, or contrary interpretation of the subject matter within the consultation. Reliance on any advice given by Jillian Silva 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 Jillian Silva either verbally, written or implied remains the property of Babies in Dreamland 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 Jillian Silva/Babies in Dreamland is confidential. Any passing of any information to anyone is strictly forbidden and subject to international copyright laws. This agreement made and entered into effective 10/10/2024 (date), is by and between you (Client) and Babies in Dreamland (Consultant). Consultation Services. The client hereby employs the consultant to perform the following services in accordance with the terms and conditions set forth in this agreement. The Consultant will consult with the Client concerning matters relating to the management and organization of implementing the sleep plan agreed upon with the client. Details as set out in section 2. 1. Terms of Agreement. This agreement comes into effect on _ . The Consultant will provide a one (1) hour consultation within two business days to the Client regarding the implementation of healthy sleep habits for the Client’s child. Following the consultation, the Client will receive the sleep plan by email within four business days of the consultation. The Client will have 24 hours to review the sleep plan and will have the opportunity to ask questions and clarify any concerns with the Consultant by email. The Client agrees to follow the plan as it is written. Following written notification (email) from the Client as to when the sleep plan will be implemented (must be within 1 week of consult), the Consultant will provide follow up support by text/email and/or phone that will end: Two weeks (14 days) after the sleep plan has been implemented. This support package includes daily text/email follow up during the first week, text/email follow up every 2-3 days during the second week, and three 15 min follow up phone calls that expire at the end of the 14 days. (Please see section 2 below, purchase of BABY CONNECT APP) All phone calls will be scheduled in advance. The agreement will terminate as outlined above. The Consultant reserves the right to terminate the agreement if the Client breaches any of the terms of this agreement. 2. Client agrees purchase Baby Connect APP to communicate and log entries of child's progress. The cost of the APP is $4.99. This is the best way for logging and communication during our consultation. Please contact me if you are unable to use the APP. 3. The Client will have to option to seek additional support from the Consultant if required at a rate of $35 for one day of email support (up to 4 email exchanges) or two 15 min calls that will expire within one week of purchase. 4. Consulting with the Client’s Health Care Practitioner. The Client agrees to consult with the Client’s pediatrician or family doctor (“health care practitioner”), about the Client’s intention to sleep train and implement the sleep plan with the Client’s child prior to sleep plan implementation. It is the Client’s responsibility to rule out any underlying medical conditions with the Client’s health care practitioner that may be causing sleep problems (i.e. sleep apnea, ear infection, allergies, asthma, etc.), as well as ensure that the health care practitioner has advised the Client’s child is gaining weight appropriately, is thriving, and that it is appropriate to implement the sleep plan and/or cease night feedings. The Client agrees to notify the Consultant of any medical changes during the sleep training process (i.e. illness, ear infection, etc.) as sleep training should not be implemented unless the child has a “healthy” diagnosis from a health care practitioner. 5. Liability and Disclaimer. The information provided by the Consultant is not intended, nor is implied to be a substitute for professional medical advice. The Client is advised to always seek the advice of the Client’s health care practitioner or other qualified health care provider with questions regarding medical conditions, or the health and welfare of the Client’s baby, toddler or child. The Consultant will use reasonable efforts to include up-to-date and accurate information in this consult, but makes no representations, warranties, or assurances as to the accuracy, currency, or completeness of the information provided. The Consultant shall not be liable for any damages or injury resulting from the Client’s access to, or inability to access the information discussed, or from the Client’s reliance on any information provided by the Consultant. The consultation may provide references to other materials and resources, but the Consultant will have no responsibility for the content of such other references and shall not be liable for any damages or injury arising from that content. Any references provided by the Consultant are provided merely as a convenience to the Client. 6. Time Devoted by Consultant. It is anticipated that the Consultant will spend approximately 6 hours of time preparing and consulting with the Client in fulfilling the Consultant’s obligations under this contract in the first week (including initial consultation and first week of support). The particular amount of time may vary from day to day at the Consultant’s discretion, however the Consultant shall devote a minimum of 20 min per day to the Client during the first 7 days of the implementation of the sleep plan. 7. Confidential Information. The Consultant agrees that any information received by the Consultant during any furtherance of the consultant’s obligations in accordance with this contract, which concerns the personal, financial, or other affairs of the Client will be treated by the Consultant in full confidence and will not be revealed to any other persons, or organizations, without written consent from the Client. The Client agrees to keep this sleep plan for the Client’s personal use and shall not share the content of the sleep plan with outside parties without written consent, with exception of the Client’s health care practitioner. Signatures. Both the Client and the Consultant agree to the above contract.I agree to the terms of this agreement* Yes Signature*
