Lullaby & Me Intake Form

Your full name *
Your baby's name*
Baby's age*
Baby's weight*
Email Address*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your baby's current daytime sleep schedule (if any)?
Was your baby a preemie? If so, what is their adjusted age?
What does your baby's bedtime routine look like? Skip if you don't have one.
What type of sleep outfit does your baby sleep in?
What does your baby's sleeping arrangement look like? Please be specific.
How many hours does your baby sleep in a 24hr period. (Naps+ Night time sleep)?
Does your baby use a pacifier to sleep.*

Yes, and I often have to reinsert it.Yes, but it's not a prop. My baby doesn't mind or cry for it when it falls out.No my baby does not use a pacifier.Other
Does your baby have any overnight feedings?*

YesNoSometimes
If you answered "Yes" for the above question. How many overnight feedings?
Is your baby or toddler formula fed, breastfed or both?
How many ounces does your baby get in a 24 hour period?
An estimate is fine
Does your baby eat solids? If so how many times a day?
Does your baby use any sleep props to fall asleep? or back to sleep during the night? Select all that apply.*

Nursing to sleepBottle to sleepRocking to sleepBouncing, swaying, or any other movementCo-SleepingDriving in the car or strolling in the strollerMy baby does not use any props to fall asleep at bedtime or during the nightOther
Which personality type best describes your baby. You may select more than one.*

Quiet, mellow, laid back, doesn't mind change.Cranky, fussy, rarely in a happy mood.Clingy, anxious, often experiences separation anxiety.Strong willed, stubborn, resists change.Happy, playful, usually in great spirits.Other
Have you tried any other methods or programs?*
What developmental milestones (if any) has your baby accomplished? Select all that apply*

None yetHolding head up when placed on bellyRolling onto sideRolling from belly to backRolling from back to bellySitting, but can't lay back downSitting, and knows how to lay back downCrawlingStanding, but can't sit back downStanding, and knows how to sit back downWalkingAll of the above milestones
Does your child have any of the following?*

Colic, GERD or Acid refluxDownsyndromAutismSensory IssuesADHD or ADDNONE
Which statement best describes how you feel about crying?*

I don't mind hearing cryingI don't mind hearing some cryingI cannot hear any crying at allOther
Please provide in detail, any additional information that will help me understand what's going on with your baby's sleep troubles. What is your end goal? If you have specific questions you can include them here too. If you forget to add something, no worries, you can always add additional information by emailing me.
How did you hear about Lullaby & Me? *
Did a friend refer you? If yes, please tell me your friends name so that I can give that person credit
Which type of Service are you interested in?*

An Evaluation & Sleep PlanPhone Consultation + Text Support/GuidanceNot sure, I would like more information.Other
TERMS AND CONDITIONS
BY SIGNING BELOW YOU AGREE TO THE FOLLOWING TERMS AND CONDITIONS:

MEDICAL DISCLAIMER: The information/advice provided during this consultation is not medical advice. You are not establishing a medical professional/patient relationship. The advice is for informational purposes only and is intended for use with healthy children with common sleep issues that are unrelated to medical conditions. The information provided is not intended nor is implied to be a substitute for professional medical advice. Always seek the advice of your physician with any questions you may have regarding a medical condition or the health and welfare of your baby.

PEDIATRICIAN APPROVAL: You agree to consult with and get approval from your pediatrician before following the advice or using the techniques offered during this consultation.

LEGAL NOTICE: In no event will Irene Makriplis or Lullaby & Me LLC be liable to you for any claims, losses, injury or damages as a result of reliance on the information provided. All though all attempts have been made to verify the information provided is accurate, Irene Makriplis does not assume responsibility for errors, omissions, or contrary interpretation of the subject matter within the consultation. Reliance on any advice given by Irene Makriplis is solely at your own risk.

REFUND POLICY: Due to the amount of time, effort, and commitment provided within a consultation, refunds are not possible once payment is submitted.

COPYRIGHT NOTICE: The information provided within the consultation may not be reproduced, republished, or transmitted in any form or by any means mechanical or electronic, including photocopying and recording, or by any information storage and retrieval system, without permission.

All information supplied by Irene Makriplis either verbally, written or implied remains the property of Lullaby & Me LLC at all times. Written permission is required to reproduce, record, publish or advise verbally any details of the provided sleep plan, E-guides, charts, notes, advice offered or consultation transcript or summary in any format whatsoever. This includes but is not limited to any details published on any blogs, forums, or similar boards. Any information supplied by Irene Makriplis/Lullaby & Me LLC is confidential. Any passing of any information to anyone is strictly forbidden and subject to international copyright laws.
Please check the box and sign below*

I have read and agree to the terms and conditions
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You will receive a response within 48 hours by email.

(Please be sure to check your spam folders.)

Thank You!

Irene Makriplis

Certified Pediatric Sleep Consultant

Lullaby & Me
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