SAS Taster Course application form
Please complete this questionnaire as fully as possible giving the details of the person the SAS Taster Course is intended for. We will select an appropriate course using this information. All information provided will remain strictly confidential.
Name of user: *
The person for whom the SAS Taster Course is intended for.
Your answer
Date of Birth: *
The date of birth of the person for whom the SAS Taster Course is intended for.
MM
/
DD
/
YYYY
Gender: *
Main area(s) of interest: *
Please tick all that apply
Required
Detailed abilities
Attention: *
Hyperactive: *
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.
Balance and coordination: *
Self-esteem / Confidence: *
Emotions: *
Behaviour: *
General temperament:
Optional.
Most likely time course will be listened to: *
Type of course: *
Choose which SAS Taster Course you prefer: A - Activating and energizing, or R - Relaxing and calming.
Course intensity: *
Select 'More intensive' for maximum brain activation, or select 'Less intensive' for lower brain activation.
Outcomes: *
Please indicate in which areas you would wish to see improvements as a result of the SAS Course. Tick all that apply.
Required
Further information:
Please provide any other information that may be relevant.
Your answer
Contact details
Your name: *
Your answer
Town or region & country *
Your answer
Telephone number:
Optional.
Your answer
Email address: *
Your course will be send to this email address.
Your answer
Confirm email address: *
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Sensory Activation Solutions. Report Abuse