Page 1 of 8
Alder Sleep Consultation Intake form
Child's first name
*
Date of Birth
*
Chronological age (e.g. 18 months)
Was baby premature?
A
Yes
B
No
If premature — adjusted age and weeks early
Child's biological sex
Birth order / siblings (e.g. first child, has older sibling age 4)
Who lives in the home? (names, relationships, ages)
Has your child attended daycare or preschool?
A
No
B
Yes, currently attending
C
Yes, previously attended
If yes — describe schedule and caregiver arrangement
Who is the primary caregiver?
*
Next, Parent/Guardian Information
