Pre- Assessment Adult Questionnaire 

To be filled out prior to assessment - if you unable to fill out yourself do let us know and we will take your information for you. 

Personal Details 

Employment/Continuing Education 

School History 

Did you have any difficulties at school with any of the following? 

Background Information 

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: 
Organisation - do you have problems with: 
Memory and Concentration: 
Literacy - do you have problems with: 
Arithmetic - do you: 
Coordination and Dexterity - do you: 
Signing and returning the Booking Form secures your date/place - Payment of invoice is due in advance by BACS before training or assessment takes place. 
An electronic invoice with banking details will be sent to the email on the Booking Form. I am afraid we 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/assessment, 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. 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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