USER REGISTRATION FORM
By completing this form you agree to SensationALL storing this data and using it to assist in the provision of appropriate support and services to you and the named user.  If you are not the parent or legal guardian of the user, you must have their consent to provide these details
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User First Name *
User Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
User Address 1 *
User Address 2
User Town/ City *
User Postcode *
Type of Accommodation *
Key Contact Name *
Key Contact Tel Number *
Key Contact Email Address *
Key Contact relationship to User *
Emergency Contacts
Please enter Emergency Contact details with daytime contact numbers.
Is the Key Contact the Primary Emergency Contact? *
If No to the above, Primary Emergency Contact Name
Primary Daytime Mobile Tel No.
Primary Daytime Landline No. (Optional)
Second Emergency Contact Name (Optional)
Secondary Daytime Mobile Tel No. (Optional)
Secondary Daytime Landline No. (Optional)
Family Composition - Number of Adults *
Family Composition - Number of Siblings *
GP Name and Practice *
School/ Education Centre Attended *
Where did you initially hear about SensationALL? *
Required
SensationALL Services
Which service(s) are you interested in? *
Required
Does the User have any allergies *
Required
Do you have an allergy care plan in place?
Clear selection
Select the primary condition which has the most significant impact on the service user? (either suspected or diagnosed) *
Please specify condition name *
Does the User have a Physical Disability *
If yes, condition name
Does the User have Epilepsy *
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
Do you have an epilepsy care plan
Clear selection
Does the user have Mental Health issues *
If yes, condition name
Does the User have Dyslexia *
Does the User have Asthma
Clear selection
If yes, please specify where they keep their inhaler and any other information we need to know in detail.
Does the User have an Asthma care plan
Clear selection
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 *
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 *
How does the user express themselves?
Please mention any non-verbal cues/ signs, symbols, trigger or keywords, echoing, electronic/ technical assistance.
Expression *
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 *
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 *
Does the user require any special equipment or adaptations to the environment?
Equipment/ Adaptation *
Please list the user’s motivators, likes, rewards and strengths?
Motivators/ Strengths *
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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