New Client Intake

I’m excited about the opportunity to work with you to enhance your relationship with rest, ensuring you achieve the rejuvenating sleep you deserve. The information you provide here will help us maximize the effectiveness of our initial session. Thank you for taking a few minutes to fill out these details.

Name
Address
MM slash DD slash YYYY
I've struggled with these issues this period of time:
My typical bed time is:
The typical time (in minutes) it takes me to fall asleep is:
Typical number of awakenings in the night is:
The amount of time it typically takes me to get back to sleep is:
List those activities you normally do during nighttime awakenings (restroom, eat, watch tv, read, use smartphone, keep trying to fall asleep, etc.)
Typical time you get up to start the day:
Do you nap in the day? If so, how often, and how long might you nap for?
Have you ever had a sleep study? If so, when and what was the finding?
How would you rate or describe your energy level during the day?

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