Sensory Suite Profile
First name
Last name
Date of birth
DD
/
MM
/
YYYY
Click to choose time
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Email
Phone
Home Address
What is your CRN (Client Reference Number)?
Emergency Contact Information
First name
Last name
Phone
Medication and Allergies
Medication - please list any medication you are currently taking
If none please say N/A
Allergies - please describe any allergies you have
If none please say N/A
Any other important information?
Communication
How do you communicate?
What would help you should you become anxious?
How do we know if you are in pain?
How do you eat?
How do you drink?
How do you move around?
Do you need help with personal care?
Any other important information?
Likes and Dislikes
Things I like:
Things I dislike:
Please indicate which of the following you can provide as supporting information:
Middle or Higher rate Disability Living Allowance (DLA)
Personal Independence Payment (PIP)
Attendance Allowance (AA)
Severe Disablement Allowance (SDA)
Certificate of visual impairment (CVI)
War Disablement Pension
A personal letter outlining your access requirement from your hospital specialist (dated within the last two months)
The Access Card (details available from www.accesscard.org.uk)
EHCP
If resident outside of the UK, please provide equivalent documentation.
Please attach supporting information.
Please attach a copy (photo/scan) of the document/s as required.
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Sensory Suite Profile Form submitted
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