Overcomer Screening Form

Sensory Processing Screen for Churches

This screening tool is designed to gather a general overview of the type of sensory tools and strategies that may benefit your church family.

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Church Name?

For each question, briefly consider if this is true for "None, A Few, or Many" of your church family. Some of the questions may help you see that a particular behavior may be related or due to a sensory processing issue. Feel free to take note of this at the end in the comments section, but please avoid using names or other identifying information. Please do not include confidential information (this is a non-HIPAA compliant tool). Thank you for your valuable input!

Seems distressed by loud noises or noisy areas

Covers ears frequently

Avoids crowds or noisy areas (Example- may act out to avoid worship service)

Frequently makes own noises, such as: humming, clicking tongue or drumming fingers

Avoids or fearful of toilet flushing, sirens, alarms or other sudden loud noises

Needs to spin, jump, rock, swing or move excessively

Frequently tips back in chair or rocks chair

Up out of their seat frequently

Fearful of playground or rough and tumble play

Frequently crashing and bumping onto the floor or into things

Breaks things frequently, has trouble grading force or pressure (Example-frequently breaks pencil lead, crayons or toys)

Hugs tightly or craves tight "Bear Hugs"

Frequently rubbing, squeezing, picking or tapping hands

Frequently fidgeting with hands (Example- playing with pen, paper, threads or anything nearby)

Touching people or things excessively

Won't keep shoes on

Avoids touch or acts negatively to touch, especially unexpected or light touch

Avoids or distressed by getting messy, such as using craft supplies like paint or glue

Avoids crowds or unstructured areas where they may get bumped into or brushed up against (Example- crowded hallways, meet & greet times, physical games, carpet story time, dismissal)

Distressed by temperature changes (Example- going from warm outside to air conditioning)

Blurting out or talking excessively when inappropriate

Chewing on inappropriate items such as their clothing or pencils

Licks or smells things inappropriately

Avoids perfumes or other strong smells

Reluctant to enter bathroom or use toilet

Avoids eating/cooking areas or food smells

Difficulty with stairs, curbs, stages or depth perception

Startles easily

Attracted to lights or shiny objects

Flaps hands or fingers in front of their eyes or face

Overly bothered by bright light, such as wearing hat or sunglasses indoors

Easily agitated when in fluorescent lighting

Crawls under chairs, tables or hides

Difficulty with transitions such as moving from one place to another or from one activity to another

Difficulty with changes in routines or structure

Tantrums, meltdowns or shutdowns

Difficulty following instructions

Overly aggressive

Easily upset or overwhelmed and/or difficulty calming down after becoming upset

Negative behaviors increase at a particular time, place or with certain activities

Comment Section: Please indicate any questions, concerns or behavior patterns that stood out to you.

We will contact you by email to schedule a time to review the results of the survey during a free consultation for your church or ministry. Thank you for your valuable input to help us better serve your church!