call us on 01590 643440 or email us

Adult Booking Form

18+ years of age

Please note: You must complete your name, email and fill in the confirmation box at the bottom of this form with YES to successfully submit it.
Where would you like the assessment?
I would like a Comprehensive Educational Assessment in my home / workplace - cost £495.00
Please note appointment times may vary slightly depending on traffic conditions.
I would like a Comprehensive Educational Assessment at the
Access Education Centre in Milford on Sea, Hants - cost £395.00
Optional extra
I would like the report produced in less than five days - cost £100
(our standard time to produce a report is 10 working days)
       
  Your Name    
     
  Home Address    
     
     
  Postcode  
 
  Telephone (Day)  
  (Evening)  
 
  Email    
     
  I prefer to be contacted by  
Telephone Email Post
 
     
  Name of person to be assessed    
     
  Home Address of person to be assessed    
     
     
  Postcode  
 
  Date of Birth  
  Age: Years     Months  
 
     
  Occupation    
     
     
If company funded,
please provide company name,
contact (e.g. HR Manager) address, tel
         
  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?    
Dyslexia Testing Previous Treatment
  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.
Dyslexia Testing Health & Development
  Do you know what your birth weight was?  
Yes   No   If yes please specify  
 
Do you know when you started to walk?
Yes   No   If yes please specify  
Do you know if there were any unusual complications during birth or early childhood?
Yes   No   If yes please specify  
Do you take any regular medication?
Yes   No  
If Yes, please name the drug and the condition for which it is taken
Have you had any serious illnesses or accidents?
Yes   No   If yes please specify  
Do you suffer from any allergies?
Yes   No   If yes please specify  
Is your health good at present?
Yes   No  
If no, please specify
Did you fidget a lot as a child?
Yes   No  
Is your hand/eye co-ordination competent?
Yes   No  
Are you good at games and sports?
Yes   No  
Are you left or right handed?
Left   Right  
Do you switch implements from hand to hand?
Yes   No  
Does anyone in your family have dyslexic-type difficulties?
Yes   No  
If so, who?
Are there any left handers in the immediate family?
Yes   No  
If so, who?
Dyslexia Testing Vision and Hearing
  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
Dyslexia Testing Speech
  Do you know what age you began to talk?  
Yes   No   If yes please specify  
 
Is English the only language spoken at home?
Yes   No   If yes please specify  
Do you have experience of speaking other languages?
Yes   No   If yes please specify  
Do you find any speech sounds difficult to make?
Yes   No   If yes please specify  
Do you express your ideas
clearly in words?
Yes   No  
Dyslexia Testing Memory
  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  
Dyslexia Testing Difficulties and Symptoms
  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.
 
 

After you submit this form, the next page you will see will confirm your details have been sent and give you the opportunity to make your payment online, should you wish to.

New - we can now accept payments online using PayPal. You can use your credit or debit card and are not required to have a PayPal account to use this service.

PayPal - The safer, easier way to pay online
Finally, could you please...
  • Post us copies of any prior dyslexia assessments
  • If requesting a home / workplace visit, please enclose local directions
Appointments
Once the booking form and background history form are received, the appointment will be secured. We will contact you to arrange a suitable time and date for the appointment.

Cancelling an Appointment
If a client cannot attend a scheduled appointment, we ask that they call to cancel at least 24 hours in advance. Missed appointments for reasons other than emergencies will be billed at the full rate.
Cancelling Tutorials
One term's notice is required (or one term's fees in lieu of notice).

Urgent Reports
If a report is needed urgently, (within 5 days), this can be arranged at a modest extra cost.

Lost Reports
If clients have lost their reports, these can be copied, re-signed and sent to you at a cost of £15.
Allergies (Atopia)
These can often be a problem for many people we see at the Centre. Can we ask that you bear this in mind and refrain from using perfumed sprays or hair gels etc on the day of testing of if attending tutorials. We use only natural products within the Centre; no 'plug-in' chemical air fresheners or spray polishes.

Thank you in advance for your consideration and co-operation.