LKC - Sleep Intake Form

Laura Kennedy Care
Sleep Questionnaire & Payment Form (USD)

Please complete this form to help me learn more about your child's sleep patterns, routines, and environment. This information allows me to create a customized sleep plan for your family.
Your full name *
Your child's name*
Please complete one form per child
Child's birthdate*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What email address did you use for payment?*
What email address will you be using for the consultation and payment?*
Do you have a spouse or partner? If so, will they be involved in the sleep training process? Please share their name:

NoYes
Please share their name and email address*
What is your child's current daytime sleep schedule (if any)?*
What is your child's current nighttime sleep schedule (if any)?*
Is your child being fed in the middle of the night? If so, please explain how often/how much:*
Is your child nursed/breastfed or bottle fed? If your child is weaned, write N/A.*
What does your child bedtime routine look like? *
Example: Bath, put on pj's and sleep sack, read a book, bottle, then rock to sleep
What type of sleep outfit does your child sleep in? Please be specific.*
What does your child's sleeping arrangement look like? Please be specific.*
Please describe, in as much detail Examples: in their own room, in a room shared with a sibling, in a crib/swing/bassinet, blackout shade on the window, sound machine, etc.
How many hours does your child sleep in a 24hr period. (Naps+ Night time sleep)?*
Does your child use a pacifier to sleep.*

Yes, and I often have to reinsert it.Yes, but it's not a prop. My child doesn't mind or cry for it when it falls out.No my child does not use a pacifier.Other
Does your child 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 movementMy child does not use any props to fall asleep at bedtime or during the nightOther
Which personality type best describes your child. 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?*
Please be sure to share any issues you had and whether or not they worked well for your family.
What developmental milestones (if any) has your child 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 milestonesOther
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
Does your child have a preferred parent?*
What are your child care arrangements?*
Please provide in detail, any additional information that will help me understand what's going on with your child's sleep troubles. 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 Laura Kennedy Care? *
Did a friend refer you? If yes, please tell me your friends name so that I can give that person credit
Do you want to start the consultation on a particular date? If not, leave today's date and I will begin working on a sleep plan right away. *Keep in mind that once the sleep plan is sent, your consultation begins from that date.

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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 child(ren).

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 Laura Kennedy Care 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, Laura Kennedy does not assume responsibility for errors, omissions, or contrary interpretation of the subject matter within the consultation. Reliance on any advice given by Laura Kennedy 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 this form is submitted.
I have read and agree to the terms and conditions
I understand that none of this is medical advice.*

I understand
I understand that there are no refunds once a payment has been received.*

I understand
I understand that payments below are charged in Canadian dollars.*

I understand.
Signature*

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Please share your availability for a call based on your timeline. Be sure to include your timezone.*
Not ready to commit yet — I’d just like to book a 20-minute intro call.

Free consultation

How would you like to work together?*

TWO-WEEK SLEEP CONSULTATION$675.00

Recommended. A personalized sleep plan designed around your child’s unique needs and your family’s routines. Includes two weeks of ongoing text support for questions or updates. This plan also includes unlimited email support throughout our work together, plus two 30-minute phone calls — one to start the plan and another to check in and wrap up.

Personalized Sleep Plan (without support)$533.00

A personalized sleep plan designed around your child’s unique needs and your family’s routines. Additional support can be added as needed and will be charged hourly.

Add-On: In-Home Support — Starting at$533.00

This fee applies to the personalized sleep plan only. In-home care is dependent on availability and varies by location, hours, and level of support. Available in Toronto and beyond.

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Laura Kennedy Care

Sleep Questionnaire & Payment Form (USD)