Child Questionnaire  to be sent with Booking Form  

Personal Details 


Development History 

Vision and Visual Difficulties 

In order to proceed with the assessment, your child MUST have a sight test within the last 6 months. In some cases, difficulties with reading are caused by visual difficulties that are not related to learning. Therefore, if, having answered the questions below, you suspect there are visual difficulties* you MUST discuss this at the eye test so that the Optician (Optometrist) carrying out the eye test, can refer your child on to an Ophthalmologist for further investigation, prior to the assessment. 
*Visual difficulties should be investigated if you answered ‘always’ or ‘sometimes’ to several questions. 
If yes please provide the following information: 

Reading and Near Work Activity 

Section for parents/carers 

Here are the choices for each questions} Never, Rarely, Sometimes, Often, Always 

Section for child 



Section for child 

School History Current National Curriculum Levels (if appropriate) 

What are the particular difficulties exhibited in school? 

Background Information 

Signing and returning the questionnaire and Booking Form secures your assessment - 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 assessments the report will be returned within 15 working days but will be retained if payment is not made. 
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. 
The information you provide on this form will be used by Positive Dyslexia to process your booking request and personal information will be kept no longer than is necessary. From time to time we would also like to send you information about our other services. 

Terms and Conditions 

1. The Booking Form must be signed and submitted to us before the assessment. Dates can only be provisionally held for 24 hours. 
2. Assessments/Training cannot be guaranteed to be rescheduled to a later date and may be charged if cancelled. 
3. A full assessment usually lasts around 3 hours for adults but may be shorter for children . Testing for Access Arrangements will be shorter. 
4. For an assessment the results will be analysed and a detailed report will be sent to you at your address within 15 working days of the appointment. 
5. Payment by BACS or cash must be made at the time of the appointment or in advance. The report will not be released until payment is made. 
6. Positive Dyslexia reserve the right not to accept a referral, to terminate an assessment or not circulate a report if: the referral appears to be outside of their area of expertise the client fails to cooperate with the requirements of the assessment procedure in such a way that may compromise the validity of the assessment the client fails to comply with the terms and conditions outlined above. 
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