Parent (1) Name
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First Name
Last Name
Occupation
Parent (2) Name (if applicable)
First Name
Last Name
Occupation
Location or Address (if applicable)
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Email
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Phone
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Preferred Method of Contact (select all that apply)
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How did you hear about Green House Doula?
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Who currently lives in your household?
Does your family have any preferred pronouns, terms, or language that I can support?
How would you describe your personal parenting style, and are there any specific approaches, philosophies, or experts that you follow or feel aligned with?
Describe your support systems (people in your life who provide you with support).
How do you practice self-care (activities, hobbies, rituals, how often, etc)?
Tell me about your own sleep hygiene. Do you have a nighttime routine? What do you do before you fall asleep? What time do you go to bed? How do you feel about sleep?
When was the last time that you have had blood work to check your thyroid function? Have you ever been iron deficient? When was the last time you had your iron, ferritin, and vitamin D levels checked?
Are you currently taking any medication or vitamins that could influence sleep? If so, please list below.
On a scale of 1-10 (10 being highest), what is your daily stress level? If you are feeling a lot of stress, what are some of the things that might be contributing to your stress level?
Do you or your partner have a history of mental health challenges? If so, what types of support are currently being sought?
Is there any family history of sleep disorders (mouth breathing, snoring, apnea, insomnia, etc.)? If yes, please provide details.
Child's Name and Age
Date of Birth. Were they late, early or on time?
Child's Birth Weight
Are there any other siblings or children in the home? If yes, please provide their name(s) and age(s).
Has your baby ever been hospitalized for any type of medical condition? If yes, please describe.
Are you currently working with, or have you previously worked with, any other specialists or practitioners besides your child’s pediatrician? If yes, please list their names and title. (e.g., IBCLC, Chiropractor, Craniosacral Therapist, Occupational Therapist, Physical Therapist, Naturopath, etc.)
Does your child have any medical conditions that impact their sleep (e.g., oral ties, apnea, asthma, eczema, allergies, reflux, etc.)?
Has your child been diagnosed with any developmental or behavioral conditions (e.g., ADHD, sensory processing differences, Autism, etc.)?
Is your child currently taking any medications or supplements? If so, please list them and indicate if any are taken close to bedtime.
Does your child tend to sleep with their mouth open or breathe through their mouth during the day? Do they snore or have noisy breathing at night, and do they wake up with a dry mouth or sore throat?
Has your child ever been evaluated or treated for oral ties, sleep-disordered breathing, or other sleep-related or developmental concerns? If yes, who performed the evaluation and what were their findings?
Have you previously worked with a Lactation Consultant? If yes, when was your last visit?
Do you currently have any concerns about your child’s nutritional intake?
Does your baby drink breastmilk, formula, or both?
If you are breastfeeding, what are your long-term breastfeeding goals?
If you are breast or bottle feeding, have you noticed:
Is there any family history of food sensitivities?
Does your child have any dietary restrictions or sensitivities (e.g., allergies, intolerances, etc.)?
Is your baby eating solid foods? If yes, at what age did they start? Are you giving purees or using baby-led weaning? Describe their nutritional intake on a typical day.
What does a typical day’s meals look like for your child (please include snacks, drinks, and ‘treats’)?
If your baby is over the age of 12 months, have you noticed:
Where is your baby/child on the growth charts? Are they following their growth curve?
If your baby has fallen off the growth curve, at what age did this happen? What has your child's pediatrician said about their weight?
Is your baby meeting all their milestones? Is there any specific milestone they're currently working on?
Please check all that apply:
Is your baby extremely sensitive to touch, taste, smell, or light and dark? Does your baby seem to really dislike tooth brushing, hair brushing, bath time, getting dressed, etc? Do you find your baby prefers more aggressive bouncing or rocking? Do they like rough and tumble play? Please describe.
Are you, or another adult who is close to your baby ill, exceptionally busy, or going through an emotionally difficult time?
Is there anything else that may be going on in your house that might be affecting your baby? Parent arguments, new nanny, new baby, a job change, a move, daycare?
Please describe the amount of time you spend with your baby and the types of activities you do together.
How much time does your baby spend playing outdoors?
How much time does your baby get per day to move freely and explore (not in a stroller, seat, or other baby container)?
Have you been away from home more than usual or taken a trip/family vacation? If yes, please describe.
Is your baby in any type of childcare (daycare, nanny, etc)? If they yes, how you feeling about the childcare and how is your little one adapting?
Tell me how you feel about tears. How do you respond to tears/frustrations from your baby during the day? Is it a priority to make those tears stop?
If your baby is over 9 months, what types of boundaries have you set for them?
Do you use any type of discipline? If yes, please describe the type of discipline you use.
Are you feeling any pressure about your parenting choices from people around you? Extended family?
What time does your child typically wake up each morning? Is this a consistent wake time or does it fluctuate?
What signals do you notice your child give when they are tired? What signals do you notice when your child is over-tired?
Does your child have a nap, rest, or quiet period during the day?
Do you have a nap time routine? If yes, please describe in detail what you do and how long it takes.
What time do you typically begin your child’s bedtime routine? What time do they fall asleep?
Please describe the bedtime routine.
On average, how long does it typically take for your child to fall asleep at nap time? At bedtime?
What clothes does your baby sleep in? Please describe the fabric of the pajamas, are they footed? Are they tight? Are there any tags? Are they footed? Etc?
Please check all that apply. We use:
If "other", please describe.
Please check all that apply:
If your baby sleeps in more than one location, please give me an idea of when your baby/child changes locations throughout the night.
What is the exact room temperature during the day? At night?
Does your baby's sleep environment get any outside noise? Loud street? Creaky floors? Subway? Television from another room? Next to a sibling's room?
Describe the lighting in your baby's sleep environment (pitch black, night light, light from hallway). If a nightlight is used, what color is the light?
Does your child use any comfort items during sleep (e.g., a blanket, stuffed animal, etc.)?
In what position does your baby sleep? (On stomach, hands under tummy, bum up in the air, on side, on back, etc?
If your baby wakes at night, do they fall back asleep independently or do they need support from you? If they need parental help, what is it that you need to do - please describe in detail.
When your baby is upset at night, what do you find is the best way to calm them other than feeding? Please describe.
Do you change your baby's diapers at any point after putting them down to bed?
Have you ever done any sleep training? If yes, please describe IN DETAIL - the method, whether you saw any success, if you used a sleep consultant (it is helpful if you provide a name so that I have a better idea of the approach used).
Are there any recent or upcoming changes in the household that might impact your child’s sleep or the ability to begin making changes to sleep (e.g., new sibling, move, parent travel, etc.)?
What are your expectations of what sleep should look like for a child of this age?
How would you describe your current struggle or concerns with sleep? Is this a new issue? When did it begin?
What are your top two priorities for your baby?
What are your top two priorities for yourself?
What are your greatest concerns about sleep work?
How would you rate your level of need currently?
If "other", please describe.
Is there any additional information that you feel would be helpful to share?