Pre-Assessment Questionnaire Pre-Assessment Questionnaire - Kelly "*" indicates required fields Step 1 of 6 16% AdministrationYour First and Last Name* First Last Partner First and Last Name* First Last Baby's First and Last Name* First Last Sibling(s) name(s) and age(s):Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Current commitments:* Your baby/toddler’s birth details and developmentBaby's Date of Birth and Current Age: Baby's Birth Weight (kg)* Baby's Current weight? (kg)* Was your baby premature? Yes No If yes babies corrected age is ...? Medical History:*Does/ has your baby had reflux or colic? Yes No If yes, please include details.Was it diagnosed/medical management/medication?Please describe your child’s physical development* Your baby/toddler’s sleep environmentPlease describe your babies sleeping situation...*Does your baby use any sleep props?* Block out blinds Dummy Digit sucking: thumb/fingers White noise Comforter Room temperature Rocking Feeding Holding (Choose all that apply) Your baby/toddler’s nutritionWhat does baby drink:* Breastmilk Formula Mix-Feed Cow’s Milk Weaned Please describe volumes if formula/frequency of feedsPlease describe frequency of breastfeedsIf baby is on solids, please explain what baby is eating and when - including volumes. Your baby/toddler’s daily sleep rhythmsWhat time does your baby wake in the morning?* Please describe your baby’s Naps*What time is bedtime and how do you settle baby/toddler to sleep at night?*How often does your baby/toddler wake overnight?*How do you settle them back to sleep*Does your baby feed overnight? If so, how often?*Does your toddler have nightmares/night terrors* Sleep Challenges and GoalsWhat have you tried to solve your problem?*How did this go?*Briefly describe your parenting style: Go with the flow/ strict routine*How would you describe your child’s temperament?*Do you have a preference for a settling technique In-room/gentle techniques Out room/cry-based techniques No preference Please describe in detail which aspect of your baby’s sleep you are finding most difficult.*What is your ultimate goal for this process?*Consent I agree to Kelly Martin Sleep Consultant Terms & Conditions: (Please note we have a 48 hour cancellation policy)SERVICES AGREEMENT These Terms and Conditions govern the relationship between the Parties. 1. Parties BETWEEN THE PARTIES Kelly Amanda Martin (abn: 88 402 078 695) of 34 Albert Street Prospect South Australia 5082 (‘Kelly Martin Sleep Consultant’) - AND- You are the client, and Your details are set out on the Invoice. Kelly Martin Sleep Consultant specializes in working with parents to develop sleep routines for their children tailored to client’s needs and requirements (the ‘Services’). You have engaged Kelly Martin Sleep Consultant to provide the Services. By continuing to work with Kelly Martin Sleep Consultant after receiving these terms and conditions, You accept the terms and conditions and agrees to the below. These Terms and Conditions are read in conjunction with the Invoice provided to You at the time of providing these Terms and Conditions (the ‘Invoice’). 2. The Engagement 2.1. Kelly Martin Sleep Consultant agrees to perform the Services for You, for the Fees, as set out in the Invoice. 2.2. Kelly Martin Sleep Consultant agrees to commence the Services upon acceptance of the Invoice and these Terms and Conditions, and upon payment of the required fees as invoiced to You. 2.3. Kelly Martin Sleep Consultant will only provide You with a refund of the Services Fee in the event they are unable to continue to provide the Services (the 'Refund'). 3. Fees and Invoicing 3.1. You agree to pay Kelly Martin Sleep Consultant the Fees set out in the Invoice. 3.2. The Fees payable to Kelly Martin Sleep Consultant to perform the Services may be adjusted from time to time as agreed by the Parties in writing (including email) on account of changes in relation to the nature of the Services to be Performed by Kelly Martin Sleep Consultant. 3.3. You agree to make Payment of the Fees upon receipt of Invoices from Kelly Martin Sleep Consultant and by the due date on each Invoice. 3.4. You agree to make Payment of the Fees by the method prescribed in each Invoice. 3.5. In the event that any payment under this Agreement is not made in full on the due date, Kelly Martin Sleep Consultant is entitled to charge You interest at the rate of 5% per annum, calculated daily. 3.6. You agree that if You default on any payments due and payable under this Agreement, any costs incurred by Kelly Martin Sleep Consultant for steps taken to enforce payment terms will be recoverable and payable by You. 3.7. You acknowledge and agree that Kelly Martin Sleep Consultant is not responsible for any third-party payment processing fees, bank fees, transaction fees, currency conversion fees and/or adverse currency fluctuations. 3.8. Unless otherwise stated, all amounts are listed in Australian Dollars (AUD) and are GST inclusive, being goods and services tax as defined in A New Tax System (Goods and Services Tax) Act 1999, inclusive amounts. Where the Services are provided outside Australia, GST is inapplicable. 4. Consulting Relationship and Disclaimer 4.1. Kelly Martin Sleep Consultant will maintain all relevant professional standards and accreditation through relevant registered training organisations. 4.2. You are solely responsible for creating and implementing Your own physical, mental and emotional well-being, decisions, choices, actions and results arising out of or resulting from the sessions and interactions with Kelly Martin Sleep Consultant. As such, You agree that Kelly Martin Sleep Consultant is not and will not be liable or responsible for any actions or inaction, or for any direct or indirect result of any Services provided by Kelly Martin Sleep Consultant. 4.3. You understand that the Services are not a substitute for medical attention, examination, diagnosis and treatment. Additionally, the Services are not to be used as a substitute for counselling and mental health care. It is your exclusive responsibility to seek such independent professional guidance as needed. 4.4. You understand that in order to enhance the consulting relationship, You agree to communicate honestly, be open to feedback and assistance and to create the time and energy to participate fully in the program. 5. Cancellation 5.1. The Services will be provided by Kelly Martin Sleep Consultant at the times agreed in the Invoice. 5.2. Should Service times require changing, a minimum of 2 business days is required or You will be expected to forfeit the full Service fee. 5.3. You must notify Kelly Martin Sleep Consultant of an intention to cancel the Services as soon as practicable through e-mail to kelly@kellymartinsleepconsultant.com.au or text message or call to 0403 521 222 and abide by the following (‘Cancellation Policy’). 5.4. All Services are non-refundable. This means that if you wish to terminate the Services early, all unpaid amounts of the Purchase Price are non-refundable. 5.5. For the sake of clarity, if you have chosen to pay through a payment plan and you wish to terminate the Services early, Kelly Martin Sleep Consultant reserves the right to immediately collect all outstanding amounts of the Purchase Price without notice by charging your method of payment, and your access to the Services will be revoked. 5.6. Kelly Martin Sleep Consultant may change the Cancellation Policy at any time without notice with and bookings made in advance of the change will not be affected. 6. Warranty 6.1. Kelly Martin Sleep Consultant will use its best efforts and take all reasonable steps to help You achieve the desired results. However, Kelly Martin Sleep Consultant makes no warranty that the Services will meet Your requirements or that all clients will achieve the same results. 6.2. The Services do come with guarantees that cannot be excluded under the Australian Consumer Law. For major failures with the Service, You are entitled to cancel Your Service contract with Kelly Martin Sleep Consultant, and are entitled to a refund for the unused portion, or to compensation for its reduced value. A major failure with the service is defined by the Australian Consumer Law and includes but is not limited to severe situations where a service is unfit for the purpose it is sold or creates an unsafe situation. 7. Liability Kelly Martin Sleep Consultant’s total liability arising out of or in connection with the Services or these Terms, however arising, including under contract, tort (including negligence), in equity, under statute or otherwise, will not exceed the resupply of the Services to You. 8. Disclosure and Use of Confidential Information 8.1. All obligations of confidence set out in this Agreement continue in full force and effect after the completion of the Services. 8.2. Both parties must not disclose any Confidential Information to any third party, including clients, and/or its agents, employees or servants, without Your prior consent. 8.3. This Agreement prohibits the disclosure of Confidential Information by both Parties with exception to the following circumstances: i. the disclosure is to a professional adviser for it to provide advice in relation to matters arising under or in connection with this Agreement and the other Party has consented to the disclosure of such information to the professional adviser; ii. the disclosure is required by applicable law or regulation; or iii. if the confidential information is already in the public domain at no fault of the other Party. 9. Force Majeure (a) If circumstances beyond ’s control prevent or hinder its provision of the Services, Kelly Martin Sleep Consultant is free from any obligation to provide the Services while those circumstances continue. Kelly Martin Sleep Consultant may elect to terminate this Agreement or keep the Agreement on foot until such circumstances have ceased. (b) Circumstances beyond Kelly Martin Sleep Consultant’s control include, but are not limited to, unavailability of materials or components, pandemics, strikes, lockouts, riots, natural disasters, fire, war, acts of God, Government decrees, proclamations or orders, transport difficulties and failures or malfunctions of computers or other information technology systems. (c) For the sake of clarity, if in Kelly Martin Sleep Consultant’s reasonable opinion, the provision of the Services will be affected by the COVID-19 Pandemic, Kelly Martin Sleep Consultant may suspend the provision of the Services in part or in whole to You indefinitely. Additionally, Kelly Martin Sleep Consultant will not be liable for any losses or damage due to the COVID-19 Pandemic. If You choose to terminate an agreement due to the COVID-19 Pandemic, cl. 5.4. will apply. 10. Dispute Resolution If a dispute arises out of, or relates to these Terms and Conditions, either party may not commence any legal proceedings in relation to the dispute, unless they attempt to resolve the disagreement in good faith, through an appropriate mediator to be appointed by independent third party, as agreed, or his or her nominee and attend a mediation. 11. Marketing You agree that any testimonials that may be provided by You from time to time may be used by Kelly Martin Sleep Consultant for marketing purposes. 12. No partnership or agency Nothing contained or implied in this Agreement will create or constitute, or be deemed to create or constitute, a partnership between the parties. A party must not act, represent or hold itself out as having authority to act as the agent of or in any way bind or commit the other parties to any obligation. 13. Governing Law & Jurisdiction 13.1. This Agreement is governed by the laws of South Australia, Australia. 13.2. In the event of any dispute arising out of or in relation to the Services, Kelly Martin Sleep Consultant agrees that the exclusive venue for resolving any dispute shall be in the courts of Australia, situated in South Australia, Australia. 14. Severance Any provision of this Agreement which is prohibited or unenforceable in any jurisdiction will, as to such jurisdiction, be ineffective to the extent of such prohibition or unenforceability without invalidating the remaining provisions of this Agreement or affecting the validity or enforceability of such provisions in any other jurisdiction. 15. Entire Agreement and Modifications Both You and Kelly Martin Sleep Consultant confirm and acknowledge that this Agreement and the Invoice constitute the entire agreement between You and Kelly Martin Sleep Consultant and shall supersede and override all previous communications, either oral or written, between the parties.How did you find out about Kelly Martin Sleep Consultant?*FriendFacebookWebsiteInstagramGoogleOtherPlease Specify