Sensory Room Information Form

Let Us Help You Create A Sensory Room

Please complete this form and one of our sensory room consultants will be in touch with you to discuss your project. Our Design Consultation Service is free and we will provide you with a computerized design and quote. We work with you until you are happy.
Name

First Name Last Name
Title
Administrator, Director, Teacher, Therapist, Caregiver, Parent, etc.
Facility Type
School, Clinic, Service Organization, Hospital, Medical, Home, Other
Facility Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
E-mail *
example@example.com
Phone Number *

Area Code Phone Number
Best Time To Call
Include Time Zone
Sensory Room Needs
Goal for Sensory Room

Calming Focus/Concentration Stimulation Socialization De-Escalation Active/Sensory Gym
Tell Us More...
We want this equipment...

Bubble or Hurricane Tubes Fiber Optics Projector Seating Vibroacoustic Tactile Features Mobile Sensory Options Vestibular Features Auditory Features Cause and Effect Features Other
Equipment We Don't Want
Sensory Room Training

Yes No
Age Range
How many people will this room serve?
How many Sensory Rooms & where will they be located?
Diagnosis
List all that apply now and in the future.
Non-Ambulatory
Just an estimated percentage
Type of Guidance Needed
Budget
Anticipated Order Date
Physical Aspects of Room(s)
Wall Type (check all that apply)

Drywall/Sheet Rock Cement Block Plaster Other
Wall Stud Type (check all that apply)

Wood Metal Other
Type of Ceiling

Tiles (Drop Ceiling) Drywall or Solid Other
Height of Ceiling
In order to provide you with a scaled, computerized drawing, please send us a sketch of your room with the following:
- Room Dimensions (each wall)
- Door Dimensions and Placement in Room
- Window Dimensions and Placement in Room
- Outlets (mark with X on the drawing)
- All permanent structures in the room (closets, bathrooms, electrical raceways, sinks, etc.)
Upload sketch or photos of room with dimensions

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Let Us Help You Create A Sensory Room

Sensory Room Needs

Physical Aspects of Room(s)