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SAAP Questionnaire for School Age Children

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Parental Sensory Attachment Intervention Consultancy

The purpose of this questionnaire is to help us to gain a more detailed picture of your child in terms of their sensory, attachment and developmental needs.

Please tick the description which best describes the frequency with which your child displays the following behaviours. Please answer all of the questions. Please write comments about your child’s behaviour in the comments section at the end of each question.

Use the following key to mark your responses

Always: Your child always responds in this manner 100% of the time

Frequently: Your child frequently responds in this manner about 75% of the time

Occasionally: Your child occasionally responds in this manner about 50% of the time

Seldom: Your child seldom responds in this manner about 25% of the time

Never: Your child never responds in this manner about 0% of the time

Comments : Explain the context in which the behaviour occurs i.e. when does it happen, write your observations of the child’s behaviour.

Child's First Name

Child's Last Name

Child's Date of Birth

Child's Age

Education Setting

Street Address

City/Town

County

Postal Code

GP

Completed By

Social Worker

Telephone Number

Today's Date

ID Number(If provided with one. If not, please leave blank)

Background

What is your relationship to the child?Birth ParentAdoptive ParentFoster ParentResidential Care WorkerOther

Other (Please Specify)

Summarise your main concerns regarding your child

If appropriate, reasons for Fostering/ Adoption

If appropriate, what age was the child when s/he first came to live with you?

Summarise the current behaviour of the child

Are there any significant events which may have contributed to your child’s behaviour? Give details.

Summarise your child’s main strengths

What are your key goals for your child?

Has your child received any previous therapy or is s/he currently receiving therapy? Please give details

Please indicate which of the following appliesThis is the first time completing this formI am completing this form for the second time after my child has had SAI InterventionI am completing this form for the third time after my child has had SAI InterventionI am completing this form for the second time, but my child has not received SAI Intervention

Please specify if appropriate

Section One: Autonomic Regulation

Tends to get infections / illALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Perspires/ sweatsALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Feels hotALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Feels coldALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Suffers from allergiesALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Finds it difficult to get to sleepALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Is a light sleeperALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Wakes up earlyALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Is a heavy sleeperALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Struggles to get up in the morningALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Suffers from constipationALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Suffers from diarrhoeaALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Suffers from both constipation and diarrhoeaALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Runs to the toilet when anxiousALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Suffers from headachesALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Doesn’t feel like eating when stressedALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Eats more when stressedALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

When stressed goes for sweet foodsALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

When stressed, goes for salty foods, e.g. crisps, salted nutsALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

When stressed, goes for citrus foods, e.g. orangesALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

When stressed goes for hot spicy foods, e.g. curry, chilliALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

When stressed, seeks to suck drinks from bottle of stream e.g. sports water bottle, carton with strawALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

When stressed, goes for crunchy foods, e.g. raw vegetables, biscuits, cerealALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

When stressed, goes for foods such as bread, pizza, pastaALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

When stressed, goes for chewy foods, e.g. chewing gum, toffee, steakALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Registers painALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Plays on regardless of feeling the pain, e.g. doesn’t stop to seek comfortALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Over-reacts to painALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Under-reacts to pain; i.e. doesn’t appear to register being hurtALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Section Two: States of Arousal

Finds it easy to relaxALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Can ignore background sights and sounds when doing homeworkALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Can ignore background sights and sounds in the classroomALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Can ignore sights and sounds in public placesALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Overly aware of background soundsALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Easily startledALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Tense or constantly vigilant when in the company of othersALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

On the look-out, checking what is happening in his/ her surroundingsALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Dislikes being aloneALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Clingy; reluctant to separateALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Tends to be noisier in group situations, when not getting 1:1 attentionALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Constantly on the goALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Finds it difficult to sit still and not fidgetALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Is quick to emotionally reactALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Gets angry with othersALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Gets angry/ frustrated with selfALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Attacks peersALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Attacks adultsALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Becomes aggressive when over-excitedALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Self-Harms; e.g. head banging, biting, cutting self, etcALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Reacts angrily when asked to do something s/he finds difficultALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Is slow to emotionally reactALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Overly compliant; obedientALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Avoids disagreeing with othersALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Is well-behaved in school but is explosive when returns homeALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Is well- behaved in school but is hyperactive/ impulsive when returns homeALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Zones out when stressedALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Becomes clumsy when stressedALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Feels lethargicALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Falls asleep in schoolALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Falls asleep on way home from school, therapy, contact, or family visitsALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Section Three: Attachment Behaviours

Hides feelings; doesn’t say when feels unhappyALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Always says “I’m fine” even when notALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Is excessively attentive to pleasing friendsALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Quiet, withdrawnALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Pretends to agree with others to avoid disagreementALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Strives hard to achieve in order to please adults, e.g. teachers, parentsALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Takes on a caring role towards parents or brothers and sistersALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Is too independent (i.e. does not want help from others)ALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Is the “too good” childALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Is obedient with adults but bullies other childrenALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Displays inexplicable outbursts then returns to being compliantALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Always wants to be the centre of attentionALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Can be highly charming in order to hold people’s attentionALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Is jealous of othersALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Can quickly change response from being charming to being threatening to becoming very upset when s/he doesn't get own way or isn't getting attentionALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Dislikes change in routine. Becomes very upsetALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Is unable to accept responsibility for own actionsALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Blames others.ALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Sets others up to get into troubleALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Looks for help a lot, even when it's not required. e.g. seeks help with dressing even though can manage independentlyALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Pretends to be ill or exaggerates symptoms of being ill in order to gain sympathy and more one-to-one attentionALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Openly engages in risk-taking behaviours (e.g. climbs onto roof)ALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Overly obedient with certain adultsALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Aggressive with certain adultsALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Stays close but does not want to be physically heldALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

Behaviour is different at home; school; respite; contact visitsALMOST ALWAYS - 95%FREQUENT - 75%OCCASIONALLY - 50%SELDOM - 25%ALMOST NEVER <1%

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Section Four: Developmental History and Sensory Processing

DEVELOPMENTAL INFORMATION

Did you / birth mother suffer from stress or medical problems during pregnancy?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Where there any complications at birth?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Did s/he have any difficulty feeding in the first year of life?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Was s/he born early or late (more than two weeks)?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Did s/he suffer much from colic?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Was s/he extremely demanding as an infant?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Was s/he extremely passive as an infant?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Did s/he feel tense when being held?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Did s/he feel floppy when being held?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

In the first three years of life did s/he suffer from any illnesses involving extremely high temperature, delirium, or convulsions?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Did s/he have a history of frequent ear, nose, throat or chest infections in the first three years of his/her life?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Did s/he suffer from allergies?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Was, or is, there a problem with wetting the bed after the age of 5 years?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Date and Result of Last Eye TestYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Date and Result of Last Hearing TestYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

PROPRIOCEPTIVE - VESTIBULAR PROCESSING

During infancy did your child dislike being placed on their stomach to play?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Had s/he difficulty learning to raise head and push up on extended arms in that position [on stomach]YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Had s/he difficulty learning to come up from lying into sitting position?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Missed out on stages of crawlingYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Learned to walk at what age?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Had difficulty learning to use pedals on a trikeYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

If yes, it is because;S/he lacked the strength to push?S/he did not know how to organise their feet to push?

Other / Comments

Had difficulty learning to use pedals on a trikePASTNOWNO DOES NOT APPLYDON'T KNOW

Is inclined to trip and fall, bump into thingsTRIPSFALLSNO DOES NOT APPLYDON'T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Struggles to correctly position body on play equipment; e.g. doesn't centre self, is half on half off, gets on back to front etcYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Constantly seeks out movement; e.g. run, jump, spin, tilt self-upside down (please specify)YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Becomes hyperactive/ over-excited/ aggressive during play (please specify)YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Seeks out rough and tumble play, the rougher the betterYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Actively avoids rough and tumble playYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Prefers a swing that gives support [e.g. a bucket seat, garden swing seat] to a single strap swing that gives no added supportYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Fearful of slidesYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Gets stuck at the top of slide. Needs help downYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Can hang from bars and maintain balance on a climbing frameYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Gets stuck on climbing frame and needs help getting offYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Likes being spun slowly on a roundaboutYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Likes being spun fast on a roundaboutYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Can kick a ball when; s/he is still, and the ball is stillYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Can kick a ball when; s/he is running, and the ball is stillYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Can kick a ball when; s/he is still, and the ball is moving towards him/herYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Can kick a ball when; s/he is moving, and the ball is movingYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Tires easily, tends to slump in a chairYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Constantly shifts about when sitting in a chairYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Has a tendency to use too much force when playing with an object or using a pencilYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Can gently handle objects if needs toYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Has a weak graspYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Is your child right or left-handed or does s/he continue to use either handYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Confuses right from leftYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Struggles with managing zips, buttons, lacesYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

TACTILE PROCESSING

Dislikes being touched unexpectedlyYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Easily irritated or angry when touched by othersYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Touch has to be on his/her terms onlyYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Easily irritated if someone accidentally pushes into him/herYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Tends to rub or scratch the spot that has been touchedYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Has a tentative approach to touching objectsYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Dislikes having hands dirtyYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Avoids walking barefootYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Dislikes the feel of tight-fitting clothingYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Dislikes the feel of labels on clothingYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Dislikes having a shower or bathYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Dislikes having a shower or bathYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Please select all that applyHates water on faceHates head being tilted/ manipulatedHates water/ soap in eyes

Other Comments:

Dislikes having a shower or bathYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Please select all that applyHates head being tilted/ manipulatedHates feel of hair on skinOther reasonDoes not apply

Other Comments:

Dislikes having nails cutYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Constantly trying to touch people and objects; can't keep hands to selfYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Appears to be unaware if touched by others or comes into contact with others. Carries on as if nothing has happenedYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Poor awareness of objects in hands, fumbles when handling objectsYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Can't match/ name hidden objects or shapes through touchYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

ORAL MOTOR

Can suck liquid through a straw.YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Can blow bubbles through a strawYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Struggled to give up sootherYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Seeks to suck; sweets, thumb, clothing, otherYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Seeks to chew non-food items; e.g. clothes, pencils, toysYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Grinds teethYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Please select all that applyWhen AwakeWhen PlayingWhen Asleep

Other / Comments

Breathes through mouth; does not close mouth & breathe through noseYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Messy Eater; i.e. does not fully close mouth, poor control of foodYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Fails to notice if face is dirty or if there is food dribbling down chinYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Dislikes the feel of toothbrush in mouthYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Only tolerates battery operated toothbrush; won't use manualYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Poor diction / pronunciation of wordsYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

VISUAL FORM, SPACE PERCEPTION AND VISUAL CONSTRUCTION

Difficulties with matching and sorting shapesYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Struggled learning to draw shapes such as a circle, square, triangle, X, etcYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Struggles with Jigsaw PuzzlesYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Please select all that applyDoesn’t visually recognise piecesHas difficulty physically placing pieces

Other/ Comments

Struggles to follow Lego step-by-step picture instructions and successfully construct objectYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Struggles with dot-to-dot drawingsYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Struggles with "spot the difference" gamesYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Has Handwriting difficultiesYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Has difficulty copying down from the whiteboardYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Has reading difficultiesYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Struggles to find objects / toys in a cupboardYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Puts on jumpers back to front/ inside outYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

AUDITORY PROCESSING

Has problems remembering sequences of instructionsYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Finds it difficult to carry out tasks on verbal instructions onlyYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Needs to be shown what to do before carrying out a taskYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Has difficulty paying attention where there are other sounds nearbyYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Is fearful of mechanical sounds, e.g. Hoover, Hairdryer, LorryYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Certain sounds are associated with bad / traumatic memoriesYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Describe the behavioural responses to these soundsYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Makes noises when working or playing, e.g. hums, sings, whistlesYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

PLAY

Has If left to his/her own devices, what sort of activities will s/he engage in?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

What sort of activities does s/he enjoy?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Will s/he amuse her/himself for long periods?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Does s/he enjoy imaginary play?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

What are the play themes?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Is the play rigid and repetitive?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Are others invited to join in?YES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Enjoys constructing an imaginary world out of cardboard or other materialsYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Has a chaotic, disorganised approach to play. Lots of ideas but then can't follow through and make them happenYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

Relies on someone else to come up with play ideasYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Tends to watch how others play before joining inYES THIS APPLIESNO DOES NOT APPLYDON’T KNOW

COMMENTS/ CONTEXT IN WHICH THIS OCCURS

Thank you for taking the time to complete this form

Sensory, arousal state, attachment & physiological profile [saap] for school-age children 2016[v1.0, 2020] Full Version. Eadaoin Bhreathnach. MSc. [Research Edition] 2020 Update

Children’s Therapy Solutions Ltd, The Barn, Friars Well Estate, North Drive, Wartnaby, Leicestershire, LE14 3HY Tel: 01664 567917

Registered in England & Wales Company Number 7339246

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Covid 19 Information

During these uncertain times, we are keen to keep you up-to-date with our service provision, which as you can appreciate is changing daily.

For reassurance CTS have set up a ‘Best Practice’ policy to ensure all our Occupational Therapists and Office Staff are working to the highest standard at all times; wherever we are based in the UK.

CTS are wanting to reassure you that we are highly committed to you and your child’s OT needs are cared for. We appreciate that a lot of our families and service users are vulnerable and many have EHCP’s in place. As a service this requires us to ensure we continue to safeguard and meet the welfare needs of our service users effectively.

We are now providing alternative therapy to continue to support children, families and in some cases parents. We are using your appointment times and making contact via phone calls, conference calls, emails, Zoom and or Skype to support Telehealth Interventions.

From the 1st June 2020 we are now seeing families at our designated CTS Clinics conforming to the recent government updates and NHS guidelines. Your Occupational Therapist will Risk Assess your child and will contact you if your child could attend

Risk Assessments will be sent out to those service users who will be attending our clinics to reassure everyone that the necessary safety procedures and precautions are being abided by; whilst still providing a positive and fun experience.Please be reassured that all staff are taking every precaution to support our country in preventing the spread of this virus.

Please continue to check this site and our Facebook page for the latest updates. Alternatively call us on: 01664 567917.

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