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RAISING BRAIN
Supporting Minds, Celebrating Diversity
Located in Northern Virginia
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Neuro-Inclusive Space Design Consult Intake Form
First Name
Last Name
Email
Phone
Child’s Name (If applicable)
Age/Grade (If applicable)
Which type of space are you seeking to design?
*
Required
Child's Bedroom (for neurodivergent child)
Classroom or Learning Environment
Business/Office
Other
Current size and layout of the space: (Please describe or provide dimensions)
Is the space currently being used, or is it a new design?
*
Required
Currently Used
New Design
Who will be using the space? (Please provide details such as age, diagnosis, or specific sensory or cognitive needs)
What specific sensory challenges or sensitivities should the design address? (Please check all that apply)
*
Required
Light sensitivity
Sound sensitivity
Tactile sensitivity (textures, fabrics)
Space and layout needs (e.g., open spaces vs. enclosed, minimal clutter)
Temperature sensitivity (heat/cold)
Visual sensitivity (colors, patterns, etc.)
Other
Are there any specific triggers or stressors to avoid in the space? (Please describe)
What are the main goals for this space? (Please select all that apply)
*
Required
Creating a calming environment
Encouraging focus and concentration
Promoting relaxation and sleep
Supporting sensory regulation
Providing spaces for sensory breaks or movement
Creating a visually stimulating or engaging space
I am not sure
Other
What specific features are important for the space? (Please check all that apply)
*
Required
Soft lighting options (e.g., dimmable lights, natural light)
Soundproofing or noise-reducing elements
Comfortable seating or sensory-friendly furniture
Sensory toys or tools (e.g., weighted blankets, fidget items)
Minimalist or clutter-free design
Flexible spaces (e.g., adjustable furniture, movable elements)
Calming colors and textures
Natural materials (e.g., wood, cotton)
I am not sure
Other
Are there any specific design styles you prefer or dislike? (Please describe)
Is there any specific equipment, furniture, or tools that must be incorporated into the design? (Please list any items that are essential or must be included)
Are there any safety concerns or special accommodations needed? (Please describe any medical, mobility, or accessibility considerations)
Please select which service you'd like (select all that apply)
*
Required
A comprehensive assessment and a detailed report outlining modifications to enhance inclusivity
Comprehensive design management services - buying + setting up
Do you have a budget for your design project?
*
Required
Yes
No
Please share any additional details or considerations that may help guide the design process
Please pick your two date/time preferences below and I will do my best to get you scheduled for your first pick. For Virtual appointments, I am available after 3:45pm on week days. We can also schedule for a weekend with 2 weeks notice.
Please complete the form, and I will reach out to you shortly. If you haven’t heard from me within 24 hours, kindly check your spam folder as sometimes my emails may end up there due to settings. Please check the box to acknowledge.
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