Pre-assessment Questionnaire – Dyslexia Diagnosis

Pre-Assessment Questionnaire – Diagnostic Literacy Assessment

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Name

This field is for validation purposes and should be left unchanged.

We are currently responding to enquiries within 3 weeks of receiving the completed form.(Required)

I understand the above

General conditions of assessment

I understand that Heidi has to work within her professional boundaries and integrity. This may sometimes affect the work that she is able to undertake or the outcomes of that work e.g., an assessment for dyslexia may not result in a diagnosis; a screening cannot result in a formal diagnosis; support with an EHCP application may not result in an EHCP being granted; any assessment may find areas of need that are unexpected. I still wish to proceed with this piece of work.(Required)

Yes

I have the agreement of all adults (and children if over 13) necessary. This may include both parents, carers/social workers, bursars and Head Teachers, as required.(Required)

Yes

Has the assessment attendee, parent/carer or partner ever served or are currently serving in the armed forces?(Required)

Yes

Who is the assessment for?(Required)

The assessment is for myself

The assessment is for my child/young person

Assessment attendee details

Assessment attendee Name(Required)

First Last

Would you like to provide a written pronunciation

Nickname

Date of birth(Required)

DD slash MM slash YYYY

Gender(Required)

Preferred pronouns(Required)

He/His

She/Hers

They/Them

Prefer not to say

If other please specify(Required)

Daytime phone number

Email address

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Nationality(Required)

If other please specify(Required)

Religion(Required)

If other please specify(Required)

Ethnicity(Required)

Parent/carer or second contact information

If you are completing this form for your child or young person, please provide your own contact details. If you are completing this form for yourself please provide a second contact information such as a partner or family member.

Parent/Carer or second contact name(Required)

Title First Last

Would you like to provide a written pronunciation?

Relationship to assessment attendee(Required)

Relationship status(Required)

If other please specify(Required)

Address

House Name/Number Street Town County Post Code Country

Daytime phone number

Mobile number(Required)

Email address(Required)

How did you hear about bibic?(Required)

If other please specify(Required)

Who lives in the house with you or child/young person? Are there significant family members living elsewhere?

Three main concerns(Required)

Select exactly 3 choices.

Academic (reading, writing, maths)

Memory and auditory processing

Learning/work environment

School (ability to manage in a classroom environment)

Visual

Fine motor (handwriting, tasks with hands)

Gross motor (movement, mobility, balance and coordination)

Language comprehension (understanding language)

Expressive language (communicating)

Other

If other please specify(Required)

What would you like to achieve from this assessment?(Required)

Is there a known diagnosis?(Required)

Yes

If yes please provide more details and dates(Required)

Is there a suspected diagnosis?(Required)

Yes

If yes please provide more details(Required)

Health and Safety

Is the assessment attendee likely to display verbal aggression whilst in the centre?(Required)

Very unlikely

Somewhat unlikely

Somewhat likely

Very likely

Please specify(Required)

Is the assessment attendee likely to display anxiety/worry?(Required)

Very unlikely

Somewhat unlikely

Somewhat likely

Very likely

Please specify(Required)

Is the assessment attendee likely to use physical behaviours when they are overwhelmed?(Required)

Very unlikely

Somewhat unlikely

Somewhat likely

Very likely

Please specify(Required)

Is the assessment attendee at risk of causing harm to themselves?(Required)

Very unlikely

Somewhat unlikely

Somewhat likely

Very likely

Please specify(Required)

Is the assessment attendee at risk of causing harm to other people in the centre?(Required)

Very unlikely

Somewhat unlikely

Somewhat likely

Very likely

Please specify(Required)

Can you tell us about any triggers?(Required)

These are to keep everyone safe within the centre

Please tell us of any accessibility needs for anyone attending the assessment(Required)

Will you need any help accessing our centre

Does anyone attending bibic have any severe allergies?(Required)

Yes

Does anyone attending bibic carry an Epi pen?(Required)

Yes

If yes please provide more information(Required)

Learning

If applicable, what is the name of their school or literacy/numeracy tutor?

If applicable, please provide the name and email address of the SENco/tutor/other educational provider

Please select your work or education setting(Required)

School mainstream

School specialist unit

School Not currently attending

School Part time

School Boarding

School PRU

School Private

School Hospital

Home educated

College Mainstream

College specialist

University

Employed

Unemployed

Self-employed

Looking for work

Other

If other please specify(Required)

What year group are they in (or what would they be in if they were attending school)?

If your child is in year 9 or above would you want this assessment to be used Exam Access Arrangements (if yes, please speak to the school and ask them to email Heidi the Form 8 with part 1 completed).(Required)

Yes

N/A

Are you happy for Heidi to contact the school or tutor to get background information (ignore this question if school are organising the assessment)?

Yes

If you choose no and require an assessment Heidi will need to see reports for the last 3 years, as well as SEN plans/IEPs and results from National Assessments in Y1,2, 4 & 6). If Heidi is supporting you in another way, she may ask you to contact the school to request the required information.

Would you like Heidi to send a copy of the report to SENco/tutor/other educational provider? (ignore this question if you are not requesting an assessment or if school are organising this assessment – they should share this report with you directly).

Yes

How does the assessment attendee manage in this setting, including behavioural responses?(Required)

How does the assessment attendee engage with learning or work?(Required)

Concentrating, engagement, change in focus, planning, organising, independence

Does the assessment attendee receive any additional support?(Required)

Yes

If yes please tell us what support they receive(Required)

Is the assessment attendee able to read to an age appropriate level?(Required)

Yes

If yes do they understand what they read?(Required)

Any other information(Required)

Enjoyment of reading, confident with reading, other information linked to learning or work environment.

Additional information

What are the assessment attendee's interests and hobbies?(Required)

What makes the assessment attendee happy?(Required)

What are the assessment attendee's strengths?(Required)

Is there any additional information you would like to share with us?(Required)

Do you have any further questions about the assessment?