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
User First Name *
Your answer
User Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
User Address 1 *
Your answer
User Address 2
Your answer
User Town/ City *
Your answer
User Postcode *
Your answer
Type of Accommodation *
Key Contact Name *
Your answer
Key Contact Tel Number *
Your answer
Key Contact Email Address *
Your answer
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
Your answer
Primary Daytime Mobile Tel No.
Your answer
Primary Daytime Landline No. (Optional)
Your answer
Second Emergency Contact Name (Optional)
Your answer
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
Details of Allergies *
Your answer
School/ Education Centre Attended *
Your answer
Where did you initially hear about SensationALL? *
SensationALL Services
Which service are you primarily interested in? *
Which of the following other services would you also like to access?
Sensory and Soft Play Hires *
Adult Group Sessions *
Holiday Group Sessions *
School Age Emotional, Social, Relaxation Groups *
Pre-school Group Sessions *
Music and Social Groups *
Family Stay and Play Sessions *
Information, Advice and Training *
Medical Conditions
Select the primary condition which applies to the user? *
Please select the type of condition(s) which apply to the user?
Autism/ Aspergers *
ADHD *
LD/ Delay *
Speech and Language Disorder *
If yes, condition name
Your answer
Sensory Impairment *
If yes, condition name
Your answer
Sensory Processing *
Developmental Coordination Disorder *
Physical Disability *
If yes, condition name
Your answer
Neurological *
If yes, condition name
Your answer
Medical *
If yes, condition name
Your answer
Genetic *
If yes, condition name
Your answer
Epilepsy *
Emotional and Behavioural *
Mental Health *
If yes, condition name
Your answer
Dyslexia *
Please explain how this impacts daily activities?
Impacts *
Your answer
Does the user have any adverse reaction to sensory stimulation?
For example photo sensitive epilepsy, easily overwhelmed, avoidance of activities
Adverse Reaction *
Your answer
Please describe any differences 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 *
Your answer
Please list the user’s motivators, likes, rewards and strengths?
Motivators/ Strengths *
Your answer
Would you like to be added to the SensationALL Newsletter *
I consent to SensationALL storing my personal data *
Submit
Never submit passwords through Google Forms.
This form was created inside of SensationALL. Report Abuse - Terms of Service