FAMILY INFORMATION FORM

PLEASE ONLY SUBMIT THIS FORM IF YOU…

* have looked at our plans and payment options

* understand that we use your answers to tell you which of our plans we recommend

* are aware that this is not a free advice service

Each form takes an average of two hours to process. Please make sure you are already familiar with the plans and cost before your assessor makes contact so that the time can be most wisely spent.

Thank you.
Team C&B

These questions have been formulated with the help of C&B Director (and Award-Winning Paediatric Nurse) Gemma, and every one is there for good reason.

Please fill them in as openly and honestly as possible, giving us the worst case scenario if needs be.

The process should take around 20 minutes.

THE FAMILY







THE CHILD






HAVE YOU ANY CONCERNS?

HEALTH...MILESTONES...DEVELOPMENTAL STAGE...REFLUX/ COLIC/ ALLERGY OR INTOLERANCE...SKIN...APPETITE...DIGESTION/BOWEL MOVEMENTS...BEHAVIOUR...

OTHER ISSUES

DO THEY SLEEP WITH THEIR MOUTH OPEN OR SNORE?DOES YOUR CHILD HAVE ENLARGED TONSILS AND/OR ADENOIDS?DOES YOUR CHILD SLEEP IN AN UNUSUAL BODY POSITION TO HELP THEM BREATHE MORE EASILY?

THE SLEEP ISSUE - DAY










THE SLEEP ISSUE - NIGHT










LOOKING DEEPER






YOUR JOURNEY







You are almost there - just a couple more minutes. In this last section, please choose which statement most closely applies to you

Q1) Which statement best describes you as a parent?

1. I am firm yet loving and am confident in my ability as a parent to call the shots/ set the boundaries/ lead the way2. I am confident setting the boundaries/ leading the way but exhaustion/guilt makes me chose different ways to those that I’d like3. I feel I have little control and am being lead by my child and it’s not working for me4. I am an entirely baby-lead, ‘attachment’ parent and it’s working for me/ I don’t want to change that

Q3) How do you feel about possible Protest/ Crying/ Resistance to the changes?

1. I understand there will be protest and why but this does not deter me2. I accept it will happen, but have mild concerns about it3. I am dreading it but have hope that I can manage4. I am not willing to continue if there is any kind of protest

Q5) Are there any factors on your or your child’s ‘emotional horizon’ such as family members’ health/pregnancy/ return to work/ starting nursery/ job issues/ mental health which might have an impact on the Sleep Support?

1. None2. Yes (please list) but we can handle that3. Yes (please list) we are concerned about overcoming this4. They may prove too difficult to overcome

Q2) How ready do you feel to make these changes?

1. We cannot go on as we are and are ready for change, however hard it is2. We are ready for change but concerned and have questions3. We have doubts about whether we are ready and do parts of the way things are now4. We are not ready and like things as they are in some ways

Q4) How do you feel about Controlled Crying?

1. I do not have a problem with it/ have done it before2. I am ok with it but shan’t enjoy it3. I feel/used to feel strongly against it but now I am coming round to the idea4. I remain inherently against it

Q6) How emotionally and mentally safe are you and your partner/ other children feeling?

1. We are exhausted but prepared for the hard work and ready to try whatever we are instructed (within reason)2. We are experiencing some of the devastating effects of sleep deprivation and it’s taking it’s toll but we are ready for the changes3. We struggle/ have struggled with some mental health issues such as PND, depression, anxiety and previous loss/ grief and we fear this may impact negatively on the result4) We have/ we’ve formerly had significant mental health considerations (PND included) and feel they may well be prohibitive to our progress

Thank you for taking the time to complete our FORM. Once we have your answers back we will tell you our recommendation as soon as humanly possible.