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?
Briefly tell me about yourself (strengths, weaknesses, likes, dislikes, personality traits, etc.)
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?
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? If yes, please provide details.
Child's Name and Age
Date of Birth
Are there any other siblings or children in the home? If yes, please provide their name(s) and age(s).
Please tell me about your Child. Who are they? What are their best qualities? What do you find most challenging about their personality?
Are you working with any other specialists or practitioners in addition to your child’s pediatrician (e.g., Chiropractor, Craniosacral Therapist, Occupational Therapist, Physical Therapist, Naturopath, etc.)?
Does your child have any medical conditions that impact their sleep (e.g., asthma, eczema, sleep apnea, etc.)?
Has your child been diagnosed with any developmental or behavioral conditions (e.g., ADHD, sensory processing differences)?
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 experience frequent illness or allergies? If so, how do you manage them?
Does your child tend to breathe through their mouth during the day or while sleeping? 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?
Do you currently have any concerns about your child’s nutritional intake?
Is there any family history of food sensitivities?
Does your child have any dietary restrictions or sensitivities (e.g., allergies, intolerances, etc.)?
What does a typical day’s meals look like for your child (please include snacks, drinks, and ‘treats’)?
Does your child consume any caffeines (including chocolate) or sugary foods, and if so, when?
What time does your child eat dinner? Do they have a bedtime snack?
Is your child fully toilet trained? If not, what stage are they in?
Does your child wake up at night to use the toilet? If so, how often?
Does your child wear pull-ups or diapers during the day and/or night?
Are there any recent changes in your child's toileting habits (e.g., accidents, bedwetting)?
Does your child have any concerns or anxieties around using the toilet, especially at night?
Do you notice any patterns in your child’s toileting routine that may affect sleep (e.g., frequent urination, constipation)?
What does your child’s bedtime toileting routine look like (e.g., do they go to the toilet before bed)?
Who cares for your child during the day? Does your child attend school or daycare, or have other regular caregivers (e.g., grandparent, sitter, nanny)? If yes, how often and for how long?
How independent is your child with self-care routines (e.g., brushing teeth, dressing themselves)?
Does your child show an interest in making decisions about their own sleep or daily habits?
How physically active is your child throughout the day? Please describe their typical activity level.
What are some of your favorite activities to do with your child, and when do you typically spend time together during the day?
Does your child participate in any sports, extracurricular activities, or structured exercise?
How much time does your child spend outside? Do you notice any changes in your child’s mood or sleep when they have more outdoor time or fresh air?
What are your child’s favorite indoor activities (e.g., screen time, reading, arts and crafts, etc.)?
How much screen time does your child have each day? What types of screens (TV, tablet, etc.) and when do they typically use them?
What time of day does your child seem most energetic? When are they typically more tired or calm?
Does your child have any noticeable energy fluctuations (e.g., bursts of energy late in the evening)?
What time does your child typically wake up each morning? Is this a consistent wake time or does it fluctuate?
Does your child have a nap, rest, or quiet period during the day? Please describe activity and length.
What time does your child typically go to bed?
Describe your child’s bedtime routine (steps, length, etc.)
Who is involved in your child's bedtime routine (e.g., siblings, co-parents, etc.)?
Does your child fall asleep independently or need assistance?
On average, how long does it typically take for your child to fall asleep at bedtime?
Does your child wake during the night? If so, how often and what is their typical behavior?
Does your child use any comfort items during sleep (e.g., a blanket, stuffed animal, etc.)?
Does your child have any particular sleep associations (e.g., needing a particular object, song, or presence of a parent to fall asleep)?
Does your child experience any of the following during sleep? Please check any that apply.
If “Other”, please describe.
Does your child take a long time to wake up or become alert in the morning? Do they seem tired or unrefreshed upon waking?
Does your child frequently appear sleepy during the day?
Where does your child sleep? (e.g., their own bed, shared room, co-sleeping, etc.)
What is your child's sleep environment like? (e.g., noise level, room temperature, light, bedding preferences, etc.)
Does your child have any sensory sensitivities or preferences that affect their sleep (e.g., sensitivity to light, textures, sounds)?
What is the average temperature of your child’s sleep space?
How dark is your child’s sleep environment?
If a nightlight is used, what color is the light?
How does your child typically handle transitions (e.g., moving between activities, starting new routines, etc.)?
How does your child handle separations from you or their primary caregiver?
How does your child typically respond to stress, big emotions, or moments of overstimulation? What calming techniques work well for them?
How does your child express their need for extra reassurance, closeness, or comfort, and when does this happen most frequently (e.g., bedtime, after school)?
Does your child have any specific fears or anxieties around bedtime?
How would you describe your personal parenting style, and are there any specific approaches, philosophies, or experts that you follow or feel aligned with?
How were you parented as a child? Are there any key positive or negative experiences that have shaped who you are as a parent?
What is your approach to discipline and setting boundaries?
How do you handle bedtime resistance, if it occurs?
How do you typically communicate upcoming changes to your child? What techniques have been most helpful?
Does your child respond well to changes in routine, or do they find them challenging?
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.)?
Have you tried any specific sleep strategies in the past? If so, what were they, and did they help?
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 child?
What are your top two priorities for yourself?
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?