CBT-I Sleep Prescription Calculator
HolistiCare CBT-I
Weekly Sleep Prescription
Active Dates:
| Calculated Sleep Efficiency: | % |
| Target Wake-Up Time: | |
| Earliest Allowable Bedtime: | |
| Clinical Adjustment: |
Next Steps / Recommendation
Rules for Sleep Checklist
- Wake up at the exact target time daily, including days off.
- Use the bed strictly for sleeping (no TV, phones, or reading).
- If unable to sleep after 30 minutes, leave the bed for a low-stimulation activity.
- Avoid daytime napping to build natural sleep drive.
- Only get into bed when actively sleepy, never force sleep.
Please upload this document to your patient portal or bring it to your next appointment.