dyslexia assessment centre
dyslexia assessment centre
  Name of Pupil    
dyslexia assessment centre dyslexia assessment centre
Date of Birth
  Age: Years     Months  
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Home Address
dyslexia assessment centre dyslexia assessment centre
 
  Postcode  
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Your Relationship to Child
 
dyslexia assessment centre dyslexia assessment centre
Telephone Number
  Email  
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Fathers Occupation
dyslexia assessment centre dyslexia assessment centre
Mothers Occupation
dyslexia assessment centre dyslexia assessment centre
Number of children in family
 
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dyslexia assessment centre dyslexia assessment centre
Child’s position in family (e.g. first)
 
dyslexia assessment centre dyslexia assessment centre
dyslexia assessment centre dyslexia assessment centre
Are there any other members of the family who have difficulties with written language?
Yes   No   If yes please specify  
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dyslexia assessment centre dyslexia assessment centre
Present School
dyslexia assessment centre dyslexia assessment centre
Is it a state or private school?
State   Private  
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dyslexia assessment centre dyslexia assessment centre
Are there any special circumstances relating to school which have affected your child’s development?
Yes   No  
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
If yes please specify below
dyslexia assessment centre
dyslexia assessment centre dyslexia assessment centre
What is your child’s attitude to school?
dyslexia assessment centre dyslexia assessment centre
At what age did his/her learning difficulties first come to your attention?
 
dyslexia assessment centre dyslexia assessment centre
dyslexia assessment centre dyslexia assessment centre
What subject areas does he/she find difficult at present?
dyslexia assessment centre dyslexia assessment centre
What subject areas is he/she good at?
dyslexia assessment centre dyslexia assessment centre
What is school’s attitude to child’s difficulties?
dyslexia assessment centre dyslexia assessment centre
Has your child had help from school?
Yes   No  
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dyslexia assessment centre
If yes, was this at school or arranged privately?
School   Private  
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dyslexia assessment centre dyslexia assessment centre
Has your child had any other treatment: e.g. visits to specialists, speech centres?
Yes   No  
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
If yes please specify below
dyslexia assessment centre
dyslexia assessment centre
Please post copies of any psychological assessment reports.
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
dyslexia assessment centre
dyslexia assessment centre
dyslexia assessment centre
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
  Birth weight  
 
dyslexia assessment centre dyslexia assessment centre
 
Were there any unusual complications in early childhood?
Yes   No   If yes please specify  
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
dyslexia assessment centre dyslexia assessment centre
Is your child’s health good at present?
Yes   No   If no please specify  
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
Does he/she take any regular medication?
Yes   No  
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
dyslexia assessment centre dyslexia assessment centre
If Yes, please name the drug and the condition for which it is taken
dyslexia assessment centre dyslexia assessment centre
Does your child suffer from any allergies?
Yes   No   If yes please specify  
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
dyslexia assessment centre dyslexia assessment centre
Has your child had any serious ailments, e.g. head injuries, fevers etc
Yes   No   If yes please specify  
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
dyslexia assessment centre dyslexia assessment centre
At what age was your child walking without help?
 
dyslexia assessment centre dyslexia assessment centre
dyslexia assessment centre dyslexia assessment centre
Does your child fidget a lot?
Yes   No  
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
Is his/her hand/eye co-ordination competent?
Yes   No  
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
dyslexia assessment centre dyslexia assessment centre
Is your child good at games and sports?
Yes   No  
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
Is your child left or right handed?
Left   Right  
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Does he/she switch implements from
hand to hand?
Yes   No  
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
dyslexia assessment centre dyslexia assessment centre
Are there any left handers in the
immediate family?
Yes   No  
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dyslexia assessment centre dyslexia assessment centre
If so, who?
dyslexia assessment centre
dyslexia assessment centre
What age did your child begin to talk?
 
dyslexia assessment centre dyslexia assessment centre
Is English the only language spoken at home?
Yes   No   If no please specify  
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
dyslexia assessment centre dyslexia assessment centre
Does he/she find any speech sounds difficult to make?
Yes   No  
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
dyslexia assessment centre dyslexia assessment centre
Does he/she express ideas clearly in words?
Yes   No  
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
dyslexia assessment centre dyslexia assessment centre
Is your child forgetful of a list of instructions?
Yes   No  
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
dyslexia assessment centre dyslexia assessment centre
Is your child forgetful of where he/she has left things?
Yes   No  
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
dyslexia assessment centre dyslexia assessment centre
Does your child have attention and concentration difficulties?
Yes   No  
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
dyslexia assessment centre dyslexia assessment centre
Have your child’s eyes been tested?
Yes   No  
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
If yes, is vision within normal limits?
Yes   No  
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
If no, please give details of any problems
dyslexia assessment centre
dyslexia assessment centre dyslexia assessment centre
Has your child’s hearing been tested?
Yes   No  
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
If yes, is hearing within normal limits?
Yes   No  
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
If no, please give details of any problems
dyslexia assessment centre
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
dyslexia assessment centre
dyslexia assessment centre
dyslexia assessment centre
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
  Please describe briefly the difficulties as they are now and your reason for seeking an assessment at this point    
dyslexia assessment centre dyslexia assessment centre
Where did you hear about Access Education?
  dyslexia assessment centre
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.
  dyslexia assessment centre
 
dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre dyslexia assessment centre
dyslexia assessment centre
dyslexia assessment centre

What is dyslexia? l Indicators of dyslexia l What to look for in Dyslexia therapy l Alternative treatments l Dyslexia in the workplace
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