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 *
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 *
Details of Allergies *
School/ Education Centre Attended *
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 *
Learning Development/Delay *
Speech and Language Disorder *
If yes, condition name
Sensory Impairment *
If yes, condition name
Sensory Processing *
Developmental Coordination Disorder *
Physical Disability *
If yes, condition name
Neurological *
If yes, condition name
Medical *
If yes, condition name
Genetic *
If yes, condition name
Epilepsy *
Emotional and Behavioural *
Mental Health *
If yes, condition name
Dyslexia *
Please explain how this impacts daily activities?
Impacts *
Does the user have any adverse reaction to sensory stimulation?
For example photo sensitive epilepsy, easily overwhelmed, avoidance of activities
Adverse Reaction *
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 *
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 *
I consent to SensationALL storing my personal data *
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