I'd like to ask you to take some time to answer some questions about your little one's sleep habits, which will allow me to learn more about their current struggles and specially what I can do to support you on your journey to good sleep!

First Name

Last Name

Child's Date of Birth * Please enter your child's date of birth.

Email * Please enter a valid email address.

Address

Your Spouse's Name? * Please enter your spouse's name.

Your Spouse's email if he / she needs access to the daily sleep log too?

Child's Name * Please enter your child's name.

Child's gender * Please select your child's gender.

Which age group does your child fall in? * Please select an age group.

Was your child premature? How was birth process?

Child is: * Please select an option.

What is his/her weight at birth? How much does he/she weigh now? * Please fill in this field.

Are there any medical conditions to be aware of? * Please fill in this field.

Are there Siblings? Age? How is his/her sleep?

Where Does Your Child Sleep? * Please select where your child sleeps.

Tell me about your child's wonderful personality, likes & dislikes * Please fill in this field.

What is the room temperature at night with aircon?

Does Your Child Use any of the Following? * Please select an option.

Does your child rely on any of the following to fall asleep? * Please select an option.

Total Screen-Time in the Day?

Is your child under the care of a nanny or helper or daycare? * Please select an option.

What time does your child wake up in the morning? * Please fill in this field.

What signals do you notice your child gives when he/she is tired? * Please fill in this field.

What time is your child napping? How do they settle? What is the duration? * Please fill in this field.

How Do You Dress Your Child to Sleep? (you can send me a picture too) * Please fill in this field.

What time is bedtime kickoff? What happens then? * Please fill in this field.

What time is your child actually falling asleep? * Please fill in this field.

What happens during the night, BEST and WORST case scenarios? * Please fill in this field.

Was there a time when your child slept well and then things changed?

What is your child's daily eating schedule? (including milk and solids if any, amount of milk if bottle feeds) How much or how long they take to finish the food? * Please fill in this field.

Any overnight milk feeds? if so, how many times and the amount or duration? * Please fill in this field.

What development stage is baby at now? trying to walk? sit? crawl? stand up? walk? talk? and how is it? * Please select a developmental stage.

When do you want to start the program?

Are they any upcoming vaccine? if so, when? or if your child has just recently taken it, when was it? * Please fill in this field.

What is your IDEAL day like wake up time and bedtime once trained? What is your goal out of this program? * Please fill in this field.

What programs or books about pediatric sleep have you explored?

Is there anything else you would like to share with me?

Who referred you to UpChild? * Please fill in this field.

UpChild community (0-6yo): we provide Sleep consultation, Baby signs course and Potty learning. Three areas feed off one another and are very important for the child and the whole family in the early years. Baby signs is for babies to learn and tell you their needs before they can talk. Cranio aims to restore health in clients at all ages.

What services are you interested?

Thank you for submitting!