HolistiCare CBT-I
Weekly Sleep Prescription
Active Dates:
| Calculated Sleep Efficiency: |
% |
| Target Wake-Up Time: |
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| Earliest Allowable Bedtime: |
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| Clinical Adjustment: |
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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.