call us on 01590 643440 or email us

Child Booking Form

Up to 17 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    
     
  Name of person to be assessed    
     
  Date of Birth  
  Age: Years     Months  
 
  Your Relationship to Child    
     
  Home Address of person to be assessed    
     
       
     
  County  
  Postcode  
 
  Telephone (Day)  
  (Evening)  
 
  Email    
     
  I prefer to be contacted by  
Telephone Email Post
 
  Fathers Occupation    
     
  Mothers Occupation    
     
  Number of children in family  
 
 
     
  Child’s position in family (e.g. first)  
 
 
     
  Are there any other members of the family who have difficulties with written language?  
Yes   No   If yes please specify  
 
     
  Present School    
     
  Is it a state or private school?  
State   Private  
 
     
  Are there any special circumstances relating to school which have affected your child’s development?  
Yes   No  
If yes please specify below
 
     
  What is your child’s attitude to school?    
     
  At what age did his/her learning difficulties first come to your attention?  
 
 
     
  What subject areas does he/she find difficult at present?    
     
  What subject areas is he/she good at?    
     
  What is school’s attitude to child’s difficulties?    
     
  Has your child had help from school?  
Yes   No  
 
     
  If yes, was this at school or arranged privately?  
School   Private  
 
     
  Has your child had any other treatment: e.g. visits to specialists, speech centres?  
Yes   No  
If yes please specify below
Please post copies of any psychological assessment reports.
 
Dyslexia Testing Health & Development
  Birth weight  
 
 
Were there any unusual complications in early childhood?
Yes   No   If yes please specify  
Is your child’s health good at present?
Yes   No   If no please specify  
Does he/she take any regular medication?
Yes   No  
If Yes, please name the drug and the condition for which it is taken
Does your child suffer from any allergies?
Yes   No   If yes please specify  
Has your child had any serious ailments, e.g. head injuries, fevers etc
Yes   No   If yes please specify  
At what age was your child walking without help?
  Years   Months  
Does your child fidget a lot?
Yes   No  
Is his/her hand/eye co-ordination competent?
Yes   No  
Is your child good at games and sports?
Yes   No  
Is your child left or right handed?
Left   Right  
Does he/she switch implements from
hand to hand?
Yes   No  
Are there any left handers in the
immediate family?
Yes   No  
If so, who?
What age did your child begin to talk?
  Years   Months  
Is English the only language spoken at home?
Yes   No   If no please specify  
Does he/she find any speech sounds difficult to make?
Yes   No  
Does he/she express ideas clearly in words?
Yes   No  
Is your child forgetful of a list of instructions?
Yes   No  
Is your child forgetful of where he/she has left things?
Yes   No  
Does your child have attention and concentration difficulties?
Yes   No  
Have your child’s eyes been tested?
Yes   No  
If yes, is vision within normal limits?
Yes   No  
If no, please give details of any problems
Has your child’s hearing been tested?
Yes   No  
If yes, is hearing within normal limits?
Yes   No  
If no, please give details of any problems
Dyslexia Testing Difficulties and Symptoms
  Please describe briefly the difficulties as they are now and your reason for seeking an assessment at this point    
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.
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.