Consultation Questionnaire

Your name *

First Name

Last Name

Is this consultation for twins/multiples? *

Yes

No

Which package are you interested in?

Newborn Sleep Consultation

Moon Package (3 days)

Star Package (7 days)

Dream Package (14 days)

Does your child have any medical conditions? *

Yes

No

How is your child currently fed? *

Breast fed

Bottle fed

Solid

Does your child use any of the following? *

Dummy/Pacifier/Soother

Comforter

Neither

Is your child sleeping through the night? *

Yes, all or most of the time

Sometimes, but not consistently

No

Is your child able to self settle? *

Yes, all or most of the time

Sometimes, but not consistently

No

Which of the following describes how you feel about crying? *

I don't mind hearing crying

I don't mind hearing some crying

I can't hear any crying

Have you tried any other sleep training methods or programmes previously? *

Yes

No

To help us offer a suitable appointment please indicate any days of the week that are *not* suitable for you: *

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Payment terms *

Please tick to acknowledge understanding that any fee due to Dear Mama is to be paid before support begins and is for her expertise, no refunds will be given.

Consent *

I confirm I have read and accept the Privacy Policy & Terms