Solden Hill House - Reasonable Adjustments Form

Name Name First Last
Organisation/Company (if applicable)
Email
Phone
Who/which home or service are you visiting?
Date of Visit (if known) Date of Visit (if known) / MM / DD YYYY
Do you require any reasonable adjustments for your visit?

Do you require any reasonable adjustments for your visit? No, I do not require any reasonable adjustments Yes – please see my requirements below I would prefer someone to contact me to discuss my requirements
If yes, please select all that apply.

If yes, please select all that apply. Step-free/wheelchair accessible access Accessible parking/drop-off point Accessible toilet facilities Seating or rest breaks Additional time for the visit/meeting A quieter meeting space Reduced noise or other sensory considerations Reduced lighting/adjustment to lighting Hearing loop or other hearing support British Sign Language (BSL) interpreter Speech-to-text/live captioning Large-print information Easy Read information Information in an alternative format Assistance with reading or completing documents Additional time to process information or respond Clear/simple verbal communication Support from a companion, carer, advocate or support worker Assistance dog Dietary requirements where refreshments are being provided Somewhere private to take medication or attend to personal/medical needs Other reasonable adjustment – please tell us below
Please tell us anything else that would help us make your visit accessible, comfortable and safe.

You only need to tell us what support or adjustment you require. You do not need to provide details of a medical condition or disability unless you feel this is relevant.
Will anyone be accompanying you to support you during your visit?

Will anyone be accompanying you to support you during your visit? Yes No
If yes, please provide their name if known. Name If yes, please provide their name if known.
Name First Last
Would you like a member of the Solden Hill House team to contact you before your visit to discuss your requirements?

Would you like a member of the Solden Hill House team to contact you before your visit to discuss your requirements? Yes No
Preferred Contact Method:

Preferred Contact Method: Telephone Email
Emergency evacuation
Do you require any assistance to leave the building in the event of an emergency?

Emergency evacuation Do you require any assistance to leave the building in the event of an emergency? Yes No Unsure – please contact me
How we use your information
The information you provide on this form will only be used to identify and arrange reasonable adjustments for your visit to Solden Hill House and, where necessary, to help us plan for your safety while you are on our premises.
Please only provide information that is relevant to the adjustments or support you require. Access to this information will be limited to members of the Solden Hill House team who need it to make arrangements for your visit. Information will be handled in accordance with our privacy and data protection requirements.
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