City of Port Phillip

Sleep and Settling Outreach - Self referral form

Please complete the referral form for further support with your child's sleep.

Once you have submitted the form, you will be contacted shortly to see how we can best support you by offering either a telephone consultation or home visit. Please note home visits are only available on Thursdays.

When you submit this form, it will not automatically collect your details like name and address unless you provide it yourself.

If you have any questions, please email sleepandsettleprogram@portphillip.vic.gov.au

Please allow 5 to 10 minutes to complete the form.

You can save and complete later at anytime using the link at the bottom of each page.

Parent/carer details

First name

Last name

Email *

Contact number

Street address

City

State

Postcode

Do you require an Interpreter? *

YesNoMaybe

Language spoken at home other than English *

Child's details

Baby's name

Date of birth

What are your concerns regarding your baby and sleep? *

Where does your baby sleep? *

How are you feeding your baby? *

Breast feedingFormulaOther

Other (please specify) *

How many feeds are you offering in 24 hours? *

Have solid foods commenced? *

YesNo

How many solid food meals do you offer? *

How do you help your baby go to sleep? *

How long have you been experiencing sleep difficulties? *

Data privacy and collection

The personal information requested on this form is being collected by the City of Port Phillip (CoPP) and will be handled in accordance with the Privacy and Data Protection Act 2014. This information will be used solely by the council for that primary purpose or directly related purposes. It will be treated in compliance with the CoPP Information Privacy Policy and the Information Privacy Act.

Yes, I give permission for the City of Port Phillip to store and process my data. *

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