Family Questionnaire So that we may provide you with the highest quality of care, please complete and submit the following questionnaire. We know may of the answers are guesses and that’s okay! Be assured we never share your information.
What is your name and your partner’s name? *
State*
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What is your child(ren)’s name and date of birth, or your due date? *
Which Do you Prefer We Use?*
How many nights per week do you wish to have service? Any preference on nights of the week? (We know this might be a guess!) *
What is your best guess for how long you’d like to have care? *
Which timeframe do you prefer? 10p-7a or 10pm-6a? We can also accommodate other times but these are the most common. *
On a scale of 1- 10, with 10 being the most important, how important is breastfeeding instruction to you? *
Are there any medical needs of which we need to be aware? *
Do you have other children? What are their names and ages? *
Do you have any pets? What type? *
Are there any food restrictions in the home? *
Where will the caregiver and child be set up? Living room? Nursery? *
We want to be sure we're helping in the best way possible, is there anything else you would like us to know? *
Who may we thank for referring you to Let Mommy Sleep? *
All fields are required.
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