Sleep Coaching : Intake Form

Date:*

Parent/s names:*

Child's name:*

Child's D.O.B & age*

Name & age of siblings:

Address

Street Address City County / State / Region ZIP / Postal Code Country

Phone no.*

Email*

GP:

Are you under the care of any other health providers:

Consent*

I agree to the Terms & Conditions & Privacy Policy.

Sleep Coaching Terms and Conditions (This can be found and re-read at any point by going to https://www.lenamackenzie.com/sleep-coaching-terms-conditions/

SLEEP COACHING T&Cs:
Please read these terms and conditions prior to our consultation, and indicate that you have read and accepted them on the sleep diary which has been sent to you.

DISCLAIMER:
Thank you for considering working with Lena Mackenzie. Support from Lena is not a substitute for medical, nutritional, lactation, psychological, therapeutic care, and it is also not a substitute for counselling, diagnosis, treatment or any other type of medical care. Please consult your doctor or other suitably qualified professional if you have any concerns regarding you or your child’s health or wellbeing.

GUARANTEES:
Coaching with Lena is educational, informative and supportive. Lena does not guarantee a particular outcome or result, or within a particular timeframe. Lena does not endorse or recommend night weaning for babies and children under 18 months, unless there are specific circumstances which make this necessary. She also never uses cry-it-out, or modified versions of it, sometimes referred to under the synonyms; ‘controlled comforting’, ‘spaced soothing’, ‘rapid return’, ‘delayed comforting’, ‘scheduled comforting’, modified extinction’, ‘graduated extinction’, ‘crying down’.

Lena will endeavour to provide you with current, evidence-based, compassionate, developmentally and age appropriate, respectful information that fits with your parenting style and does not compromise attachment or responsive parenting. She will not ask you to do anything you do not feel comfortable with, and there will never be a requirement for you to stop breastfeeding or bed-sharing (when applicable) as long as this is in the best interests of you and your child.

EQUALITY & NON-DISCRIMINATORY PRACTICE:
Lena promotes an inclusive, non-judgmental service, and will not knowingly discriminate against anyone on the basis of their race, sexual orientation, parenting style, disability, cultural beliefs, marital status or religion. If there is anything you would like Lena to be aware of, please make this clear at the beginning of the consultation.

SCOPE OF PRACTICE:
By choosing to work with Lena, you understand that she will not tell you what to do, but will work with you to find a solution that is sustainable for your family. She will make suggestions and provide education and information based on her training and experience. You are responsible for whether you choose to implement any suggestions offered.

Lena is also a qualified Clinical Hypnotherapist, NLP & EFT practitioner, perinatal emotional health & birth trauma relief practitioner, birth & postnatal doula and mindfulness & meditation facilitator, and relationship coach. However, by working with Lena as a sleep consultant, you agree that you are consulting her in relation to sleep and wellbeing alone. Any other queries or concerns can be addressed either separately, or by an alternate practitioner.

IN PARTICULAR, BY CHOOSING TO WORK WITH LENA, YOU AGREE THAT:
- You will work within SAFE SLEEP GUIDENLINES which can be found here: https://www.basisonline.org.uk/
- You will disclose any relevant medical problem that may have a bearing on sleep
- You understand that if Lena is concerned for the welfare of your child, she has a duty to report this to the relevant health and/or safeguarding service in your local area. This will always be with your knowledge except in cases where the immediate safety of the child takes priority.
- You understand that you will be providing certain personal details which are required to be kept. All information is stored with password protection and will never be shared with any other third party.
- In the event of you choosing to be invoiced for services, rather than paying online, payment is required within 48 hours of the initial consultation or contact.
- YOUR SLEEP SUPPORT IS BESPOKE TO YOU & SHOULD NOT BE SHARED WITH THIRD PARTIES, as the information may not be relevant. There is no one-size-fits-all approach.

CANCELLATION POLICY:
It is your parental right to cancel at any time if you do not feel that sleep coaching is right for you or your child. For cancellations made more than 48 hours before, or for re-scheduled appointments due to illness etc there is no charge. For cancellations less than 48 hours prior to the appointment, a 50% refund will be issued. For cancellations less than 24 hours prior to the appointment, the full fee is payable.

If Lena has to cancel, she will offer an alternative appointment which will be mutually convenient to both parties.

If, after reading your sleep diary, Lena genuinely feels that a different approach with an alternate practitioner would be more in your interests, then she will issue a full refund, regardless of how soon the appointment is.

FOLLOW UP & AVAILABILITY:
Lena will provide support as set out in the package you have purchased. If applicable, Jay will send a written summary of the consultation, with the suggestions discussed in the meeting, within 48 hours of the appointment - If there is a time issue, Lena will let you know during your appointment or as soon as possible.

Lena generally does not work on weekends or public holidays, and therefore any contact on these days will be answered on the next working day.

Lena works internationally, and resides in the UK, on GMT or British Summer Time (GMT+1). She will endeavour to be flexible for her international clients, but will not generally answer emails or calls outside of 9am-8pm UK time.

Lena provides extensive support following an initial consultation. Depending on which package you have chosen, this support may be a scheduled phone call at a mutually agreeable time, or emails. Emails can be initiated by you, and Lena will let you know when your follow up package is drawing to a conclusion. You can purchase additional follow up if required, though this is rarely necessary. If you do not answer calls or emails, or initiate contact, then it will be assumed that you no longer need or want sleep support.

COMMENTS, COMPLIMENTS & COMPLAINTS
Lena strives to provide a high-quality service that meets your needs. If you have enjoyed working with Lena and feel that you and your family have benefitted from her expertise, please consider sending in a review. In the unlikely event that you are not satisfied with the service JLena has provided, within the terms and conditions stated here, then in the first instance, please contact Lena personally, who will try to resolve the dissatisfaction.

Lena enjoys good working relationships with all her clients, and she looks forward to hearing all about you and your family in the near future. If you have any questions at any time about this service, please email hellolenamac@gmail.com

Privacy & Security:*

Understand and accept

Please note that I keep your information in a password protected environment, and I keep your identifiable information separate to that of the questionnaire and notes. Any documents that I send to you, I will send password protected. The password will be your child’s date of birth, for example if born on the 15th December 2019, the password would be 15122019. By replying by email, text, WhatsApp, Messenger etc, you are doing so on the understanding that I cannot encrypt or lock away, other than my electronics are always password protected and kept either locked within my home or securely with me when out and about. By messaging me by other means, you are automatically granting me permission to save your number, email address and to respond via that service.

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Sleep Coaching: Intake Info & Consent