Family Profile:

∙ Proudly Serving the Las Vegas Valley ∙

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?

What is your address?

What is your child(ren)’s name and date of birth, or your due date?

What is your phone/text number and email?

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 the approximate date for service to begin?

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 support 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 would like the caregiver and child to be set up?

Is there anything else you would like us to know? Do you have any requests we may accommodate?

Who may we thank for referring you to Let Mommy Sleep?