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Focus Call Questionnaire

Child Birthdate
What is the single area of struggle you wish to focus on in our session?
Does your child have any of the following I need to be aware?
My child uses the following:
Does your child rely on anything external to fall asleep?
Where does your child sleep?
In Your Room
In Their Own Room
With a Sibling
My child is currently:
Home with Me
With a Nanny/Caregiver
At Daycare
How often is your child up in the night?
0- Sleeps Through The Night
1-2 Times
3-4 Times
5+ Times

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