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Dyslexia in adults- Post 16 questionnaire

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Dyslexia can be diagnosed at any age. Fill out the questionnaire if you wish to go ahead with an assessment or if you have any worries about posssible dyslexia.

You can fill it out to give you an idea of your strengths and challenges - if you find you are answering yes to many questions do give us a call or send the completed form to us for further advice what to do next. Filling out does not tie you to an assessment.

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

Full Name:

Date of Birth:

Mobile Number:

Email Address:

Office Number:

Home Address:

Employment/Continuing Education

Are you currently in work?

Yes

No

Have you gained any qualifications such as GCSE's/A Levels? If so what grades did you achieve?

Are you currently taking a course of study?

Yes

No

If YES, what are you studying?

Where are you studying?

Is your course of study?

Part Time

Full Time

No Applicable

What year of study are you in?

Have you studied any other courses since leaving school?

Details:

College

University

Date:

Course:

Qualification Gained:

School History

Which Secondary School did you attend ?

What subjects were you good at?

How old were you when your difficulties were first noticed?

Did you have a good relationship with your teachers?

Yes

No

Did you work as hard in school as you might have done?

Yes

No

Did you have to work harder in order to keep up with the others in your class?

Yes

No

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

Essays:

Slight

Moderate

Severe

Revision:

Slight

Moderate

Severe

Sports and Games:

Slight

Moderate

Severe

Did you have any specialist help at school?

Yes

No

Please give details, (e.g. Teaching Assistant, extra time in exams, Statement/EHCP, specialist tuition:

Was your schooling disrupted in any way? eg by illness .

Yes

No

At what age did you leave school?

Have you ever seen any other specialists (e.g. speech specialists) or been assessed for learning difficulties such as dyslexia?

Yes

No

If a written report was given, can you let us have a copy?

Yes

No

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:

Orientation:

Do you have difficulty telling left from right?

Yes

No

Do you find it hard to remember directions?

Yes

No

Do you have difficulties reading road signs especially when driving?

Yes

No

ls map reading, or finding your way to a strange place confusing?

Yes

No

Arithmetic - do you:

Tend to forget mathematical operations that are used infrequently?

Yes

No

Find it hard to calculate sums in arithmetic without a calculator?

Yes

No

Find it difficult to do calculations in your head?

Yes

No

Coordination and Dexterity - do you:

Please summarise your difficulties and say if there is anything you would like the assessment to help you with in particular. Please include any information which you feel may be relevant and submit with the Booking Form . If this is difficult for you then we will take this information on the day of the assessment.

TERMS & CONDITIONS

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.

CANCELLATION CHARGES

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.

Please confirm:

You agree to abide by our Terms & Conditions

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.

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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