Private & confidential
Young person’s information form
Every young person coming to this event should complete a separate form. Please
give as much information as you can. The information is used to help make sure that
we meet the needs of everyone attending and to ensure we provide suitable activities.
1. Young person’s details
Full name:
Address:
Postcode:
Date of birth:
Age:
Tel no:
Mobile:
Male/Female
E-mail:
Do you require written communication in any other format?
Yes/No
(Standard will be size 14 Arial)
If yes, please provide further details
Is there anyone else you would like us to talk to about your needs?
Yes/No
If yes, please give details including full name, relationship to you and contact details.
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2. Abilities & disabilities
If applicable, please describe your disabilities:
Do you have a learning disability?
Not at all
□
Moderately □
Severely
□
Profoundly □
Not easily □
assessed
Hearing
Please describe your hearing and reaction to sound:
Please tell us more about your use of hearing, reaction to sounds and any aids that
you use:
Vision
Please describe your sight and reaction to light:
Please tell us more about your use of vision, reaction to light and any aids you use:
Mobility
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Tell us about how you get around indoors. Please include information about any aids
you use, how many steps you can climb and about distances.
Tell us about how you get around outdoors. Please include information about any
aids you use, how many steps you can climb and about distances.
Do you use any handling equipment? For example slide sheets, slings, transfer
boards?
Yes/No
If yes, please give further details
If you use a wheelchair, can you weight bear?
Yes/No
Do you have limited movements in any part(s) of your body that we should be aware
of?
If yes, please give further details
3. Communication
What communication methods do you use? (please tick)
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Speech
BSL
SSE
Objects of reference
Deafblind manual
Gesture
Total communication
Facial expressions
Photographs
Makaton
Symbols
Key words
Other (please specify)
Please describe in detail the communication methods you use, for example specific
signs/gestures.
How do other people communicate with you? (please tick)
Speech
BSL
SSE
Objects of reference
Deafblind manual
Gesture
Total communication Facial expressions
Photographs
Makaton
Symbols
Key words
Other (please specify)
Please describe in detail the communication methods you receive, for example
specific signs/gestures.
How do you communicate choices about what you do and do not want to do?
How do you communicate how you are feeling for example angry, upset, frustrated
or happy?
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4. Emotions & behaviour
Do you have any behaviour that other people find difficult to manage? Yes/No
If, yes, can you describe this behaviour (how often does it happen, how long does it
last, how intense is it, how long does it last, how severe is it, who is affected?)
Any precursors or signs that behaviour might escalate?
What triggers can produce this behaviour?
What past strategies have been successful or unsuccessful to manage this
behaviour?
Do you have any fears or phobias, for example the dark, dogs etc?
Do you have a sense of danger?
Yes/No
If no, please give details:
Do you have any sexual behaviour/awareness that will impact on others that we
need to know about?
Yes/No
If yes, please give details
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5. Daily routines- please use additional sheets, if necessary
Toilet – Do you use a toilet independently?
Yes/No
If no, what support and assistance do you need for example full support, or the level
of supervision.
Do you wear incontinence aids?
Yes/No
If yes, do when do you wear them?
For female attendees – what support do you need to manage your period?
6. Food and drink
We will all gather together at lunch time and volunteers will not be available, so the
parent/carer will have to ensure the child is fed during this break. However, if parents
and carers are not attending the event, please make sure this section is filled in and
we can provide this support.
Do you follow a special diet or have any food allergies?
Yes/No
If yes, please give further details:
Do you have a history of chest infections?
If yes, please give details
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Yes/No
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Have you had any input from a Speech and Language Therapist about eating and
drinking
Yes/No
If yes, please give details
Does your food need to be served in any particular way, for example blended or
mash?
Yes/No
If yes, please give details
Do you have difficulties eating / chewing, drinking or swallowing, eg coughing,
putting too much food in your mouth, choking
Yes/No
If yes, please give details
Do you need any special equipment to help you eat?
Yes/No
If yes, please give details
Any specialist equipment will need to be brought
If you use a feeding tube, please tell us what type and provide any further details
below
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Do you need any help or have any specific routines that should be followed when
you are eating or drinking?
Yes/No
If yes, please give details
Do you have a good appetite?
Yes/No
If no, please give further details
What is the usual number of meals you have each day?
What are the usual portion sizes?
What is the usual number of snacks you have each day?
What is the usual number of drinks you have each day?
How much from the cup do you usually drink?
All □
Half the cup □
A few sips □
7. Medical Needs
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Refuse to drink □
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Please tell us about any medical conditions you have.
Do you have epilepsy?
Yes/No
If yes, how do you manage your epilepsy? Please give details of anti-epileptic
drugs taken, preventative measures and emergency medication.
Doctor's name:
Address:
Postcode:
Telephone no:
Please give details of any medication you are taking. Please state whether the
medication is routine, occasional or emergency.
Name
Purpose
Amount
Delivery
When is it
The name of
What is it for
In units
method
taken?
the medication
Oral, rectal etc
Is there any other information relating to your medication we should know, for
example, side effects or strictness of timing?
What non-prescribed treatment (e.g. paracetamol or Calpol) do you take for
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complaints that occur from time to time such as headaches or earache? Please
give further details below:
Complaint
Treatment
What support, if any, do you need to take your medication?
Have you had any infectious diseases or been in contact with any infectious
diseases recently? If yes, please give further details. This information will not
prevent participation on the day.
Do you have any known allergies and how do you control them?
Who should we contact in an emergency?
Name:
Relationship to you:
Address:
Phone number:
8. Miscellaneous
Written guidelines
Do you have a
Personal passport / communication plan?
Written plan on how to manage your epilepsy?
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Yes/No
Yes/No
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Behaviour support plan?
Yes/No
Moving and handling guidelines?
Yes/No
Is there anything else we should know for the day to run smoothly?
9. Signature: To be signed by the person who completed the form
Signed:
Date:
Name - if not completed by young person:
Relationship to young person:
Address (if different to young person’s address):
Contact number:
10. Permission: To be signed by the parent or guardian
I agree for treatment (under current law) to be given if the necessity arises in case
of emergency.
Signed:
Date:
Sense holds a database of information about the people who use our services, which helps us plan
and improve what we do. We would like to use the information you supply on this form and on the
equal opportunities monitoring sheet to make a database entry. This will be confidential, secure and
for Sense’s use only (under the provisions of the Data Protection Act.) If you do not wish a database
entry to be made, please tick the box.
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