Sensory Processing Screening SPD04

Sensory Processing Screening SPD04

(Please note this is not intended as an official diagnosis, but can highlight sensory difficulties which could indicate referrals to the relevant professionals (such as an Occupational Therapist, for example) may be appropriate).
Child's Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Completed by
Name of Person who Completed this Form:

NameSurname
Address

Street Address

Street Address Line 2

CityCounty

Postal Code
Phone Number

Area CodePhone Number
Email address (that you would like the results sent to)
example@example.com

Please answer the following questions according to your child's level of sensitivity.

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
Dislikes being hugged or touched
Becomes upset or anxious with light and unexpected touch
Startles easily by unexpected sounds
Struggles with bright light
Overreacts to being bumped or touched by other children when playing
Refuses certain clothing - bothered by tags, scratchy, tight or uncomfortable clothing
Is a ‘picky’ eater and refuses foods because of their smell or texture
Is overwhelmed by crowds and prefers quieter places
Seems to constantly need to touch people or textures even when socially unacceptable
Has no understanding of personal space and gets very close to people when talking
Has an extremely high pain tolerance
Doesn’t realise their own strength (e.g. hurts others when hugging)
Is extremely fidgety and cannot sit still
Deliberately and frequently seems to bump into things
Is calmed by deep pressure (strong hugs or weighted blankets, for example)
Craves fast spinning and/or intense movement (such as hanging upside down)
Frequently jumps on couches/beds and other furniture
Becomes upset when things are out-of-place/been moved
Has difficulty following instructions
May produce own sound, hum or talk when competing tasks
Enjoys loud background music
Has difficulty following a moving object (or person) with eyes
Complains about having tired eyes
Often loses place when ready/copying information down
Writes on a significant slant
Seems oblivious to details of objects and surrounding environment
Doesn’t notice smells or odours
Doesn’t notice tastes or care if food is spicy
Doesn’t want to explore their environment or join in with other children
Dislikes trying physical activities
Has volumes of TV etc louder than is comfortable for others
Uses a loud voice – sometimes shouting level when speaking
Unable to stop talking and has difficulty waiting turns
Enjoys noisy environments
Mouths or bites objects beyond developmentally appropriate age
Bites or rubs skin
Attracted to flickering lights
Is captivated by screens (TV, gaming, Ipads etc) and spend hours watching
Smells, people, animal or objects
Constant desire to chew gum
Desires crunchy food
Likes one particular type of food – salty, sweet, sour, etc
Bites on sleeves, pencils, etc – always has something in their mouth
Frequently falls on the floor or rolls intentionally
Enjoys intense movement such as flipping, rolling, being upside down
Constantly asks for roughhousing, tickling, play fighting
Is not calmed down by additional movement input; can get worse
Appears not to hear instructions and/or often doesn’t reply to questions
Hears background noise that others appear not to notice

Additional comments
At ABC Psychotherapy we take your privacy very seriously and only use your personal information to provide you with access to our therapy. This document will be retained for 7 years in accordance with the Data Protection Act (DPA) 1998.
Should be Empty: