Dyslexia, dyslexia testing and dyslexia and educational assessments, hampshire, uk


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Full Name

Date of Birth

		Age: Years				Months

Home Address

		Postcode

Telephone Number

		Email

Occupation

If you are a full time student, which school, college or university do you attend?

Which course are you undertaking? (subject and level, e.g. Post Grad / Degree / HND etc)

Are there any other members of the family who have difficulties with written language?

Yes		No		If yes please specify

At what age were your difficulties first noticed?

What do you consider to be your particular strengths?

What do you consider to be your particular weaknesses?

Did you ever receive any help at school?

Yes		No		If yes please specify

Were you educated in the state or private sector?

State		Private

Did you have any treatment that may be connected with your current difficulties: e.g. visits to speech therapists or specialist teachers?

Yes		No

If yes please specify below



Please post copies of any psychological assessment reports.

Have your eyes been tested?

Yes		No

Is vision within normal limits?

Yes		No

Please give details of any problems

Has your hearing been tested?

Yes		No

Is it within normal limits?

Yes		No

Please give details of any problems

Are you forgetful of a list of instuctions?

Yes		No

Where you have left things?

Yes		No

Do you have attention and concentration difficulties?

Yes		No


	Please describe briefly your major difficulties and why you are seeking an assessment

	Where did you hear about Access Education?

	Please confirm you have completed this form by typing YES, in capital letters, into the box provided.		I have completed this form, where appropriate, and it is to the best of my knowledge accurate.