CBT‑I Intake Form • Your Sleep Clinic

CBT‑I Intake Form

Please complete this form before your consultation. You’ll be able to download a PDF copy and email it to info@yoursleepclinic.com.

1) Your Details

Full name

Date of birth

Phone

GP / Primary care provider

How did you hear about us?

Consent

I consent to coaching, understand this is not medical care, and agree to data being used to deliver services and communicate with me.

2) Presenting Concerns

What brings you to CBT‑I? (e.g., trouble falling asleep, frequent waking, early waking)

How long has this been an issue?

Initial trigger(s) if known

Top 3 goals for sleep

3) Typical Sleep Pattern (averages)

Usual bedtime (weeknights)

How long to fall asleep (minutes)

Number of awakenings

Total time awake during the night (minutes)

Final wake time

Out of bed time

Weekend schedule different?

Nap minutes per day (avg)

Total time in bed (hours)

Estimated total sleep time (hours)

Tip: Rough averages are fine. We’ll refine with a sleep diary if needed.

4) Daytime Function & Impact

Daytime sleepiness (0–10)

Fatigue / energy (0–10; higher = worse)

Mood/irritability (0–10; higher = worse)

How is sleep affecting your life/work/relationships?

5) Health, Medications & Substances

Medical conditions (relevant)

Medications & supplements (dose/time)

Caffeine (type & daily amount)

Alcohol (units/week)

Nicotine or vaping

Other substances (if any)

6) Sleep Environment & Behaviours

Share bed/room with partner or pets?

Screens in bed (mins before sleep)

Exercise (type & weekly mins)

Noise/light/temperature issues?

Any concerns about safety (e.g., falls, parasomnias)?

7) Snoring / Apnoea Risk (screening)

Do you snore loudly?

Has anyone observed you stop breathing during sleep?

Morning headaches?

Sleepiness while driving?

Neck circumference (cm) if known

If risk is elevated, we may suggest discussing a medical referral with your GP. CBT‑I can still proceed alongside medical evaluation.

8) Brief Sleep Beliefs & Distress

How much do you worry about sleep? (0–10)

How much control do you feel you have over sleep? (0–10)

Motivation to follow plan (0–10)

Submission & Download

After you complete the form, click “Download my completed form (PDF)”. Then attach it to an email to info@yoursleepclinic.com.

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