SAS Client Questionnaire
Please complete this questionnaire as fully as possible giving the details of the person the SAS course is intended for. You are under no obligation by completing this questionnaire. We will contact you prior to proceeding.
Client name: *
The person for whom the SAS course is intended for.
Your answer
Age Group: *
Gender: *
Main area(s) of concern: *
Please tick all that apply
Required
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: *
Writing: *
Drawing / 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.
Required
Further information:
Please provide any other information that may be relevant.
Your answer
Contact Details
You are under no obligation by completing these details. We will contact you prior to proceeding.
Your name: *
Your answer
Your address:
Your answer
Country: *
Your answer
Telephone number / Skype name:
For Coached Courses 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
Your interest: *
Please tick all that apply.
Required
Offer Code (if any):
Your answer
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