CONFIDENTIAL QUESTIONNAIRE FOR ADULTS & POST 16 

PERSONAL DETAILS  

EMPLOYMENT/CONTINUING EDUCATION  

Yes
No
Yes
No
Part time
Full time
College
University

SCHOOL HISTORY  

Yes
No
Yes
No
Yes
No
Did you have any difficulties at school with any of the following?  
Slight
Moderate
Severe
Slight
Moderate
Severe
Slight
Moderate
Severe
Slight
Moderate
Severe
Slight
Moderate
Severe
Slight
Moderate
Severe
Slight
Moderate
Severe
Yes
No
Yes
No
Yes
No
Yes
No

BACKGROUND INFORMATION  

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

CURRENT DIFFICULTIES  

ln day to day experiences at work, or on courses you have taken, have you had difficulties with any of the following: 
 
Communication - do you: 
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
 
Organisation - do you have problems with: 
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
 
Memory and Concentration:  
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
 
Literacy - do you have problems with: 
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
 
Orientation: 
Yes
No
Yes
No
Yes
No
Yes
No
 
Arithmetic - do you: 
Yes
No
Yes
No
Yes
No
 
Coordination and Dexterity - do you: 
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

TERMS & CONDITIONS  

Signing and returning the Booking Form secures your date/place - Payment of invoice is due in advance by BACS in advance. A separate invoice with banking details and will be sent to the email on the Booking Form. I am afraid I cannot accept personal cheques. 
For INSET sessions a copy of the presentation will emailed in advance with any handouts to be photocopied by the school ( preferably on non white paper). 
If there are over 50 attendees the trainer will need to be notified in advance. 
For assessments the report will be returned within 15 working days but will be retained if payment is not made. 
 

CANCELLATION CHARGES  

1. If you are unable to go ahead with the training/assessments, you must advise Positive Dyslexia as soon as possible, at least 48 hours in advance. 
2. Positive Dyslexia will endeavour to rearrange the date to a mutually convenient time. 

DATA PROTECTION ACT 2018 

The information you provide on this form will be used by Positive Dyslexia to process your booking request. From time to time we would also like to send you information about our other services. 
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