SAS At Home Client Questionnaire
Please complete this questionnaire as fully as possible giving the details of the person the SAS At Home course is intended for. Your course will be custom designed by an experienced SAS Practitioner using this information.
Client name: *
The person for whom the SAS At Home course is intended for.
Your answer
Age Group: *
Gender: *
Main area(s) of concern: *
Please tick all that apply
Detailed Conditions
Attention: *
Concentration: *
Distraction: *
Hyperactive: *
Impulsive: *
Understanding: *
Sense of time: *
Understanding different time spans such as 10 minutes, one hour, yesterday or last week. Being able to plan activities ahead for the whole day. Being able to read a traditional round clock face.
Short Term Memory: *
Long Term Memory: *
Speech Development: *
Reading speed: *
Reading accuracy: *
Writing speed: *
Writing accuracy: *
Handwriting: *
Fine motor skills: *
Gross motor skills: *
Balance: *
Self-esteem: *
Confidence: *
Emotions: *
Behaviour: *
Strong willed: *
Perfectionist: *
General temperament: *
Most likely time programmes will be listened to: *
Outcomes: *
Please indicate in which areas you would wish to see improvements as a result of the SAS Programme. Tick all that apply.
Further information:
Please provide any other information that may be relevant.
Your answer
Contact Details
Your name: *
Your answer
Full postal address including post-code: *
Your answer
Country: *
Your answer
Telephone number / Skype name:
If you wish to proceed we'll make an appointment to contact you by telephone or Skype to discuss your requirements.
Your answer
Email address: *
Your answer
Confirm email address: *
Your answer
SAS At Home course selection: *
Preferred language: *
The instructions will be in English, but the actual programmes can be supplied in a number of languages.
Never submit passwords through Google Forms.
This form was created inside of Sensory Activation Solutions.