Current | Preliminary Questionnaire w. Payment I'd like to ask you take a few minutes to answer some questions about your child's sleep habits before we talk in person. This will help me prepare for our meeting, and will let us make the best use of our time together. There are quite a few questions, but almost all of them can be answered in just a sentence or two, so please don't be intimidated! Once you have worked through the questions below, simply submit and follow the links to my Terms and Conditions and my 'Travel Tips' information sheet. If you could get it back to me at least two days before we are scheduled to meet, I would appreciate it. Thanks, Tara MitchellYour DetailsParent/s name/s*Email* Phone*Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How did you hear about The Gentle Sleep Specialist?*In a couple of words, we'd love to how you found us? Google, Instagram, Facebook, Friend etcAbout Your ChildYour child's name*Please complete one form for each child.Date of Birth* Date Format: DD slash MM slash YYYY Are you breast feeding or bottle feeding?*BreastBottleIf bottle feeding, how much?Was your child premature?*YesNoIf yes, by how much?Does your child have colic?*YesNoHas your child had any other health issues or concerns?*YesNoIf yes, please give brief details.Is your child on any medication?*YesNoPlease provide details of the medication.About Your Child's SleepHave you spoken to a Doctor about your child's sleeping difficulties?*YesNoWhat was the outcome?Does your child use a dummy?*YesNoWhat time does your child wake to start their day?*Describe what happens at this time. Are they breastfed, given a bottle, start with solids etc?What signals to you notice your child gives when he or she is tired?What time of the day does the first nap usually occur and where does it take place?How do you get your child to sleep for this first nap?What time of the day does the second nap occur and where does it take place?How do you get your child to sleep for the second nap?Is there third or fourth nap taking place in the day or evening? If so, please give details.What time do you start getting your child ready for bed?What do you do when getting them ready for bed?What time does your child actually fall asleep at bedtime?How does your child fall asleep at this time?What happens during the night? (Best AND worst case scenarios)Have you read any books about infant sleep?YesNoIf so, have you tried any suggestions from these books in the past?Is there anything else you would like to share with me that you think I should know before we meet?Terms and Conditions.*You need to scroll to the bottom of the Terms and Conditions before accepting them - please ensure you read them. Thank you.Terms of Service*The Gentle Sleep Specialist The information provided by The Gentle Sleep Specialist is for informational purposes only and is intended for use to assist with common early childhood sleep issues that are wholly unrelated to medical conditions. Information provided either via The Gentle Sleep Specialist website, Facebook page, through written correspondence, or provided verbally is not intended to be a substitute for medical advice or treatment. Always seek the advice of your doctor or other qualified health practitioner regarding any matters that may require medical attention or diagnosis, and before following the advice and using the techniques described from The Gentle Sleep Specialist and Sleep Sense Program. Reliance on any information provided by The Gentle Sleep Specialist is solely at your own risk. Exclusion/Limitation of Liability The Gentle Sleep Specialist does not make any representations or warranties, express or implied, regarding consulting services provided. In no event will The Gentle Sleep Specialist be liable for any loss, damage, injury, liability, cost or expense of any nature. Terms & Conditions for Packages. These terms and conditions apply to the following packages: Baby Bundle, Sleeping Beauties, Sleeping Gems, Saving Sleep, Sleepy Tots & Life Ready. All consultation fees must be paid prior to commencement of initial consult. The Gentle Sleep Specialist reserves the right to postpone and or cancel consultation should payment not be finalised. Should the client choose not to proceed after the initial consult, prior to receiving the emailed plan, the client is eligible for a 20% refund on the initial sum paid for the package. Should the client choose not to proceed after the initial consult, once the plan has been emailed or at any stage during the first week follow up period the client is eligible for a 10% refund of the initial payment for the package. Should the client choose not to proceed during the final week of follow up, no refund will be given. The Gentle Sleep Specialist takes no responsibility for the results of the program. If the Client becomes uncooperative, threatening, or if there is reason to believe that the parent is not taking reasonable steps to ensure the care and safety of the Child, The Gentle Sleep Specialist reserves the right to terminate services without refund. The Gentle Sleep Specialist’s packages include once-daily follow up phone calls initiated by Tara Mitchell. Reasonable attempts will be made each day to make contact, however if the client is not answering the phone, The Gentle Sleep Specialist is not responsible, and no refund or substitute service will be provided. During the two weeks follow up, should The Gentle Sleep Specialist may choose to send follow-up SMS text messages in place of a phone call if the Client and the Child are doing well. If you are an international Client, phone follow up will usually be replaced with Skype arrangements and SMS text messages on every second day. As a participant in The Gentle Sleep Specialist program, the Client is expected and encouraged to always follow SIDS safe guidelines. Should you need to put the program on hold after commencement of the program, arrangements will be at the discretion of The Gentle Sleep Specialist. By undertaking this program you are agreeing to certain aspects of controlled crying, there is no pressure to continue however refunds remain as stated above. Definitions: “The Gentle Sleep Specialist”: Tara Emma Mitchell, or any employee or contractor of The Gentle Sleep Specialist. “Client”: the person receiving the services and/or information provided by the Gentle Sleep Specialist. I have read and agree to the Terms of Service Please read and accept the Terms + Conditions prior to submitting your form. Payment MethodPrices are inclusive of GST.Package Name*Make a selectionBaby Bundle | Expectant Parents & Newborns (8 weeks & Under)Sleeping Beauties | Phone Consultation PackageSleeping Gems | 90 minute In-Home ConsultationSaving Sleep | 5 Hour In-Home ConsultationSleepy Tots | 3 Hour In-Home ConsultationOther amount (as advised)Expectant Parents & Newborns (8 weeks and under)Phone Consult ($195.00)In Home ($ 295.00)Sleeping Beauties | Phone Consultation PackageOne Child ($495.00)Twins (+$150)Sleeping Gems | 90 minute In-Home ConsultationOne Child ($595.00)Twins (+$150)Saving Sleep | 5 Hour In-Home ConsultationOne Child ($ 995.00)Twins (+$100)Sleepy Tots | 3 Hour In-Home ConsultationOne Child ($795)Twins (+$100)Other Amount *(only used if advised)Total $ 0.00 Credit Card Card Details Cardholder Name *Important*Once you have submitted this form, please check your email for a receipt of confirmation. If you do not receive this email, we may not have received your details. Please allow up to 30 minutes for delivery and be sure to check your SPAM folder. If you have received the confirmation, Tara will be in touch as arranged. EmailThis field is for validation purposes and should be left unchanged. Return to home page of The Gentle Sleep Specialist Current | Preliminary Questionnaire w. Payment I'd like to ask you take a few minutes to answer some questions about your child's sleep habits before we talk in person. This will help me prepare for our meeting, and will let us make the best use of our time together. There are quite a few questions, but almost all of them can be answered in just a sentence or two, so please don't be intimidated! Once you have worked through the questions below, simply submit and follow the links to my Terms and Conditions and my 'Travel Tips' information sheet. If you could get it back to me at least two days before we are scheduled to meet, I would appreciate it. Thanks, Tara MitchellYour DetailsParent/s name/s*Email* Phone*Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How did you hear about The Gentle Sleep Specialist?*In a couple of words, we'd love to how you found us? Google, Instagram, Facebook, Friend etcAbout Your ChildYour child's name*Please complete one form for each child.Date of Birth* Date Format: DD slash MM slash YYYY Are you breast feeding or bottle feeding?*BreastBottleIf bottle feeding, how much?Was your child premature?*YesNoIf yes, by how much?Does your child have colic?*YesNoHas your child had any other health issues or concerns?*YesNoIf yes, please give brief details.Is your child on any medication?*YesNoPlease provide details of the medication.About Your Child's SleepHave you spoken to a Doctor about your child's sleeping difficulties?*YesNoWhat was the outcome?Does your child use a dummy?*YesNoWhat time does your child wake to start their day?*Describe what happens at this time. Are they breastfed, given a bottle, start with solids etc?What signals to you notice your child gives when he or she is tired?What time of the day does the first nap usually occur and where does it take place?How do you get your child to sleep for this first nap?What time of the day does the second nap occur and where does it take place?How do you get your child to sleep for the second nap?Is there third or fourth nap taking place in the day or evening? If so, please give details.What time do you start getting your child ready for bed?What do you do when getting them ready for bed?What time does your child actually fall asleep at bedtime?How does your child fall asleep at this time?What happens during the night? (Best AND worst case scenarios)Have you read any books about infant sleep?YesNoIf so, have you tried any suggestions from these books in the past?Is there anything else you would like to share with me that you think I should know before we meet?Terms and Conditions.*You need to scroll to the bottom of the Terms and Conditions before accepting them - please ensure you read them. Thank you.Terms of Service*The Gentle Sleep Specialist The information provided by The Gentle Sleep Specialist is for informational purposes only and is intended for use to assist with common early childhood sleep issues that are wholly unrelated to medical conditions. Information provided either via The Gentle Sleep Specialist website, Facebook page, through written correspondence, or provided verbally is not intended to be a substitute for medical advice or treatment. Always seek the advice of your doctor or other qualified health practitioner regarding any matters that may require medical attention or diagnosis, and before following the advice and using the techniques described from The Gentle Sleep Specialist and Sleep Sense Program. Reliance on any information provided by The Gentle Sleep Specialist is solely at your own risk. Exclusion/Limitation of Liability The Gentle Sleep Specialist does not make any representations or warranties, express or implied, regarding consulting services provided. In no event will The Gentle Sleep Specialist be liable for any loss, damage, injury, liability, cost or expense of any nature. Terms & Conditions for Packages. These terms and conditions apply to the following packages: Baby Bundle, Sleeping Beauties, Sleeping Gems, Saving Sleep, Sleepy Tots & Life Ready. All consultation fees must be paid prior to commencement of initial consult. The Gentle Sleep Specialist reserves the right to postpone and or cancel consultation should payment not be finalised. Should the client choose not to proceed after the initial consult, prior to receiving the emailed plan, the client is eligible for a 20% refund on the initial sum paid for the package. Should the client choose not to proceed after the initial consult, once the plan has been emailed or at any stage during the first week follow up period the client is eligible for a 10% refund of the initial payment for the package. Should the client choose not to proceed during the final week of follow up, no refund will be given. The Gentle Sleep Specialist takes no responsibility for the results of the program. If the Client becomes uncooperative, threatening, or if there is reason to believe that the parent is not taking reasonable steps to ensure the care and safety of the Child, The Gentle Sleep Specialist reserves the right to terminate services without refund. The Gentle Sleep Specialist’s packages include once-daily follow up phone calls initiated by Tara Mitchell. Reasonable attempts will be made each day to make contact, however if the client is not answering the phone, The Gentle Sleep Specialist is not responsible, and no refund or substitute service will be provided. During the two weeks follow up, should The Gentle Sleep Specialist may choose to send follow-up SMS text messages in place of a phone call if the Client and the Child are doing well. If you are an international Client, phone follow up will usually be replaced with Skype arrangements and SMS text messages on every second day. As a participant in The Gentle Sleep Specialist program, the Client is expected and encouraged to always follow SIDS safe guidelines. Should you need to put the program on hold after commencement of the program, arrangements will be at the discretion of The Gentle Sleep Specialist. By undertaking this program you are agreeing to certain aspects of controlled crying, there is no pressure to continue however refunds remain as stated above. Definitions: “The Gentle Sleep Specialist”: Tara Emma Mitchell, or any employee or contractor of The Gentle Sleep Specialist. “Client”: the person receiving the services and/or information provided by the Gentle Sleep Specialist. I have read and agree to the Terms of Service Please read and accept the Terms + Conditions prior to submitting your form. Payment MethodPrices are inclusive of GST.Package Name*Make a selectionBaby Bundle | Expectant Parents & Newborns (8 weeks & Under)Sleeping Beauties | Phone Consultation PackageSleeping Gems | 90 minute In-Home ConsultationSaving Sleep | 5 Hour In-Home ConsultationSleepy Tots | 3 Hour In-Home ConsultationOther amount (as advised)Expectant Parents & Newborns (8 weeks and under)Phone Consult ($195.00)In Home ($ 295.00)Sleeping Beauties | Phone Consultation PackageOne Child ($495.00)Twins (+$150)Sleeping Gems | 90 minute In-Home ConsultationOne Child ($595.00)Twins (+$150)Saving Sleep | 5 Hour In-Home ConsultationOne Child ($ 995.00)Twins (+$100)Sleepy Tots | 3 Hour In-Home ConsultationOne Child ($795)Twins (+$100)Other Amount *(only used if advised)Total $ 0.00 Credit Card Card Details Cardholder Name *Important*Once you have submitted this form, please check your email for a receipt of confirmation. If you do not receive this email, we may not have received your details. Please allow up to 30 minutes for delivery and be sure to check your SPAM folder. If you have received the confirmation, Tara will be in touch as arranged. PhoneThis field is for validation purposes and should be left unchanged.
