Form Test

Medical information
Doctor’s name:
Address:
Street Address Address Line 2 City County / State / Region Postcode Country
Telephone number
Immunisations:
Care Manager/Social Worker:
Telephone number:
Email:
Enter Email Confirm Email
Any other services/professionals involved e.g. wheelchair services, therapies, doctors, respite care, PA/carers, community teams?
In order for us to process your application and assess your needs, we may need to contact external agencies such as educational establishments, medical professionals or similar third party agencies. Permission to contact:
- Yes
- No
Please provide information about your diagnosis:
Do you have any medical problems e.g. allergies, asthma, diabetes, heart problems?
- Yes
- No
If yes, please give details
Do you have epilepsy?:
- Yes
- No
If yes, please give details, attach care plan
(If yes, please give details, attach care plan)
Do you have any difficulties with vision or hearing?:
- Yes
- No
If yes, please give details and contact information for any support services
Is there anything else you would like to tell us about your health and medical needs/ support?
If you have marked ‘Yes’ to any of the above, please send in copies of any guidelines, support plans and risk assessments with this form.

Behavioural information
Do you display any challenging behaviour?
- Yes
- No
If yes, please give details:
How is your behaviour managed?
What may trigger behaviour?
What helps?
Do you use any services that offer support? e.g. CAMHS, psychology, art therapies
- Yes
- No
If yes, please give details:
If you have marked ‘Yes’ to any of the above, please send in copies of any guidelines, support plans and risk assessments with this form.

Communication
How do you communicate? e.g. speech, signs, vocalisations, facial expressions, pictures/symbols
What helps you understand? e.g. simple instructions, symbol timetable, signing
Please give any information about any equipment you use to support communication e.g. BigMack, Step by step, Communication book (symbol/photo book), PECS

About you - your likes and dislike
Likes: what makes you happy, things you like to do e.g. watching TV, reading, music, routines Dislikes: e.g. no shouting, food you don’t like, physical touch
Things you like
Things you don’t like