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SAS Starter Course application form
Please complete this questionnaire as fully as possible giving the details of the person the SAS Starter Course is intended for. We will select an appropriate course using this information. All information provided will remain strictly confidential.
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* Indicates required question
Name of user:
*
The person for whom the SAS Starter Course is intended for.
Your answer
Date of Birth:
*
The date of birth of the person for whom the SAS Starter Course is intended for.
MM
/
DD
/
YYYY
Gender:
*
Choose
Male
Female
Other
Main area(s) of interest:
*
Please tick all that apply
Learning Enhancement
Cognitive Ability
Work/Study Performance
Emotional Well-Being
Social Skills
Behavioural Issues
Eating & Sleeping
Compulsive Behaviour (OCD)
Learning Difficulties
Attention Deficit Hyperactivity (ADHD)
Dyslexia, Reading & Writing
Physical Development
Sensory Processing Difficulties
Speech & Language
Asperger's Syndrome
Autistic Spectrum Disorder
Down's Syndrome
Brain Disorder
Other:
Required
Detailed abilities
Attention:
*
Choose
Excellent
Good
Age appropriate
Poor
Very poor
Don't know / Not applicable
Hyperactive:
*
Choose
Not at all
Rarely
Age appropriate
Often
Mostly
Don't know / Not applicable
Understanding:
*
Choose
Excellent
Good
Age appropriate
Poor
Very Poor
Don't know / Not applicable
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.
Choose
Advanced
Age appropriate
Poor
Very poor
Minimal
Don't know / Not applicable
Balance and coordination:
*
Choose
Advanced
Age appropriate
Poor
Very poor
Minimal
Don't know / Not applicable
Self-esteem / Confidence:
*
Choose
High
Age appropriate
Variable
Low
Very low
Don't know / Not applicable
Emotions:
*
Choose
Overly
Somewhat
Age appropriate
Rarely
Disconnected
Don't know / Not applicable
Behaviour:
*
Choose
Excellent
Good
Age appropriate
Challenging
Extreme
Don't know / Not applicable
General temperament:
Optional.
Choose
Ambitious and energetic (choleric)
Pleasure-seeking and sociable (sanguine)
Introverted and thoughtful (melancholic)
Relaxed and quiet (phlegmatic)
Passive and lethargic (supine)
Don't know / Not applicable
Most likely time course will be listened to:
*
Choose
Morning
Afternoon
Evening
While asleep
Various times
Do not know yet
Type of course:
*
Choose which SAS Starter Course you prefer: A - Activating and energizing, or R - Relaxing and calming.
A - Activating
B - Relaxing
Course intensity:
*
Select 'More intensive' for maximum brain activation, or select 'Less intensive' for lower brain activation.
More intensive
Less intensive
Meditation
*
Select if you wish to include 15 minute guided mediatations on days 2, 4, 6, 8, 10 and 12, to activate relaxation of body and mind.
With meditation
Without meditation
Outcomes:
*
Please indicate in which areas you would wish to see improvements as a result of the SAS Course. Tick all that apply.
Hearing
Vision
Speech development
Pronunciation
Use of language
Reading ability
Writing ability
Expressive writing
Mathematics
Understanding
Learning ability
Following instructions
Social interactions
Behaviour
Balance / Coordination
Fine motor skills
Gross motor skills
Self-esteem
Mood / Emotional stability
Toilet training
Eye contact
Attention
Hyperactivity
Impulsivity
Eating habits
Sleeping habits
Use of medication
Other:
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
Name of SAS Provider:
If you are in contact with a SAS Provider, please state their name, otherwise leave blank.
Your answer
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