Please enter Emergency Contact details with daytime contact numbers.
Is the Key Contact the Primary Emergency Contact? *
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Yes
No
If No to the above, Primary Emergency Contact Name
Your answer
Primary Daytime Mobile Tel No.
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Primary Daytime Landline No. (Optional)
Your answer
Second Emergency Contact Name (Optional)
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Secondary Daytime Mobile Tel No. (Optional)
Your answer
Secondary Daytime Landline No. (Optional)
Your answer
Family Composition - Number of Adults *
Your answer
Family Composition - Number of Siblings *
Your answer
GP Name and Practice *
Your answer
School/ Education Centre Attended *
Your answer
Where did you initially hear about SensationALL? *
Required
SensationALL Services
Which service(s) are you interested in? *
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Does the User have any allergies *
Required
Do you have an allergy care plan in place?
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Select the primary condition which has the most significant impact on the service user? (either suspected or diagnosed) *
Please specify condition name *
Your answer
Does the User have a Physical Disability *
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Yes
No
Undiagnosed
If yes, condition name
Your answer
Does the User have Epilepsy *
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Yes
No
Undiagnosed
If Yes, please specify the seizure presentation, how long does a seizure normally last, what are common triggers of an episode, does the user take medication
Your answer
Do you have an epilepsy care plan
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Does the user have Mental Health issues *
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Yes
No
Undiagnosed
If yes, condition name
Your answer
Does the User have Dyslexia *
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Yes
No
Undiagnosed
Does the User have Asthma
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If yes, please specify where they keep their inhaler and any other information we need to know in detail.
Your answer
Does the User have an Asthma care plan
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Does the user have any adverse reaction to sensory stimulation?
For example photo sensitive epilepsy or are they overwhelmed by noise/lights/motion etc.
Adverse Reaction *
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Please describe any differences or reactions the user has with sensory experiences?
This may relate to play, self-care, being outside, self-stimulatory or repetitive behaviours (involving all senses).
Sensory Experiences *
Your answer
How does the user express themselves?
Please mention any non-verbal cues/ signs, symbols, trigger or keywords, echoing, electronic/ technical assistance.
Expression *
Your answer
What language/ communication does this user understand?
Please mention any requirement for visual aids, structure, objects of reference, difficulties with social communication, literal understanding, the need for repetition etc.
Communication *
Your answer
Please summarise any challenging behaviours that the user presents?
Please summarise any behaviours that the user presents which are challenging or likely to be problematic or dangerous within the facilities of SensationALL. Please also outline any individualised management or approach used with them.
Challenging Behaviours *
Your answer
Does the user require any special equipment or adaptations to the environment?
Equipment/ Adaptation *
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Please list the user’s motivators, likes, rewards and strengths?
Motivators/ Strengths *
Your answer
Would you like to be added to the SensationALL Newsletter *
SensationALL may take photographs or videos of our service users and these images may appear on videos/our website and social media. Do you give media consent
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I consent to SensationALL storing my personal data *
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