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Family Questionnaire - April 2021
Family Questionnaire - We are currently experiencing a particularly high demand for dyslexia assessments due to the effects of Covid-19 on schooling and working arrangements. In many cases this is causing a long lead time between initial enquiry and the undertaking of the Helen Arkell assessment. Some forms of assessment currently have a 6-month waiting time.
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Family Questionnaire - We are currently experiencing a particularly high demand for dyslexia assessments due to the effects of Covid-19 on schooling and working arrangements. In many cases this is causing a long lead time between initial enquiry and the undertaking of the Helen Arkell assessment. Some forms of assessment currently have a 6-month waiting time.
This form takes approximately 20-30 minutes to complete and some of the questions are compulsory. Please scroll down to answer questions. Press Submit once you have completed the questionnaire.

PLEASE DO NOT PRINT THIS FORM. To fill in a form by hand, please return to our website where you will find a printable pdf form

It is important that this questionnaire is completed as fully as possible; this will enable us to support your child in the most effective way.

N.B. Please be aware that it may not always be possible for a formal diagnosis of a specific learning difficulty to be made as the result of an assessment.

Helen Arkell Charity is a registered charity in England and Wales (1064646). Whilst great care is taken in all matters, the Charity cannot accept liability or responsibility for any advice given by the professionals to whom the Charity refers the child/adult (assessee).

We are totally committed to protecting your information and using it responsibly. Please read our policy carefully to understand how we collect, use and store your information. https://www.helenarkell.org.uk/about-us/privacy-policy.php
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Your child's details
Child's full name: *
Date of birth: (please use this format "1st September 2006") *
Gender:
Clear selection
Parent's / Guardian's details for correspondence
Full name(s): *
Title: *
Relationship to child: *
First lines of your address : *
Town / City *
Postcode: *
Home telephone:
Work telephone:
Mobile telephone:
Email address:
Please indicate your preferred contact method(s). *
Required
Name and address of parent(s) / Guardian(s) to whom the report should be sent if different from above. The report will only be sent to named persons.
Family background
It helps to know who is part of your child's family. Please complete appropriate sections.
Father's Name:
Father's Age:
Father's Occupation:
Mother's Name:
Mother's Age:
Mother's Occupation:
Sibling 1 Name:
Sibling 1 Age:
Sibling 1 Occupation or School / College:
Sibling 2 Name:
Sibling 2 Age:
Sibling 2 Occupation or School / College:
Details for any further siblings, i.e. Name, age, etc:
Details of any other carer:
Does your child live with both parents? *
If no, please explain the situation:
Was your child adopted:
Clear selection
If yes, is your child aware of the adoption:
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If yes, at what age was your child adopted:
Languages
Is English your child's first language: *
If No, how long has English been spoken:
If No, what languages are spoken in the home:
If No, does your child experience any difficulties in his / her first language:
Clear selection
Speech, language, literacy and numeracy
Learning is complex, it is helpful to know if other family members have struggled in these areas
Has your child's father ever struggled with: *
Required
Has your child's mother ever struggled with: *
Required
Has your child's siblings ever struggled with: *
Required
Has your child's other relatives ever struggled with: *
e.g. grandparents, uncles, aunts, cousins.
Required
If Yes, which relatives:
Pregnancy, birth and early development
It is very useful to know about your child's very early life and development
Were there any problems during pregnancy with this child:
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Was the pregnancy full term:
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Was the delivery normal:
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What was your child's weight at birth:
Please give details of any difficulties indicated above:
Were there any difficulties in the early months, e.g. sucking or feeding: *
If yes, please give details:
If possible, please state at approximately what age your child first sat up: *
If possible, please state at approximately what age your child first crawled: *
If your child did not crawl, please explain how he / she moved around:
If possible, please state at approximately what age your child first walked: *
Did your child show a clear preference for one hand: *
At what age was a preference apparent:
Has that preference remained unchanged:
Clear selection
Speech, language and communication development
This relates directly to learning
At approximately what age did your child begin to use a few words: *
Was your child understandable outside the family by the age of 3 years: *
If your child has ever mispronounced any sounds, please give details:
Is this ongoing:
Clear selection
If your child has ever jumbled or mispronounced words, please give details:
Is this ongoing:
Clear selection
In the past, did your child have problems with: *
Yes
No
Clarity of speech
Understanding spoken language
Self expression
Please give details of any difficulties noted above:
In the present, does your child have problems with: *
Yes
No
Clarity of speech
Understanding spoken language
Self expression
If any of these are ongoing, please give details:
Has your child ever had speech, language and communication assessment or therapy: *
If Yes, please send copies to questionnaire@helenarkell.org.uk
If a report is not available, please give details
Medical History
Information about your child's health is important
Has your child had any of the following: *
Please tick all that apply.
Required
Please give details of any accidents or any hospitalisation your child has had:
Please give details of any illness or conditions that the assessor should be made aware of:
Does you child suffer from: *
Please tick any that apply
Required
Is your child on any medication? *
Required
If yes, please give details
Is your child normally healthy: *
If no, please give details:
Is your child on a special diet, or are any foods avoided: *
If yes, please give details:
When was your child's last sight test? (month / year) *
N.B. If more than 2 years ago, please book a sight test before the assessment takes place. This is a professional standards requirement.
To give us further information on your child's sight please complete the Visual Difficulties Screener at the end of this questionnaire.
How is your child's hearing: *
Yes
No
Has your child's hearing been tested (within the last 2 years)
Does your child have a history of ear infections
Do you think your child hears normally at the moment
Have you ever thought your child may have a hearing loss
Please give any relevant details for the above:
Has your child had surgery for: *
Please tick all that apply.
Required
Please give any relevant details for the above:
Activity and behaviour
Has your child ever had difficulty with: *
Please tick all that apply.
In the past
Ongoing
No
Jigsaw puzzles
Lego
Colouring/drawing
Dressing
Using cutlery
Tying shoelaces
Catching balls
Throwing balls
Climbing stairs
Cycle riding
Co-ordination
Clumsiness
Toilet training
Bedwetting
Hyperactivity
Tantrums
Discipline
Long silences
Sleeping
Nightmares
Anxiety
Eating
Food textures
Being withdrawn
Following verbal instruction
Remembering nursery rhymes
Learning times tables
Learning to read/spell
Organisation
Concentration
Attention
Please give any further information you feel is relevant:
Education
Please give details of your child's education to date: *
School(s) followed by start date and end date (or current) and whether State or Independent
Has your child missed a lot of school: *
Are there reasons other than age for changing schools:
Clear selection
If Yes to either of the above, please give details:
Has your child had extra tuition outside of school: *
If Yes, please give details of when (which years), how often (per week), with whom (job title) and in what subjects:
Has your child had support in school: *
If Yes, please tick all that apply:
If Yes, please say when (years) and how often (number of times per week)
Does your child have any other therapy: *
If Yes, please give details:
Has your child been assessed previously by an Educational Psychologist: *
If Yes, please send a copy of the report to questionnaire@helenarkell.org.uk
If Yes, please give details (when, by whom etc):
I have sent/will send a copy of the report to the Helen Arkell Charity:
Clear selection
Has your child been assessed previously by any other professional e.g. Specialist teacher / Occupational therapist: *
If Yes, please send a copy of the report to questionnaire@helenarkell.org.uk
If Yes, please give details:
I have sent/will send a copy of the report to the Helen Arkell Charity:
Clear selection
Both Helen Arkell Specialist Assessors and Educational Psychologists can diagnose Dyslexia. Are you aware of any additional difficulties that your child experiences which means it may be more appropriate for him / her to have an educational assessment by a psychologist rather than a specialist assessor: *
If Yes, please give your reasons:
Parents views and concerns
What are your reasons for arranging an assessment?
What is your concern about your child: *
What is your view of the difficulty: *
What views, if any, has your child expressed: *
What special interests/hobbies/talents does your child have: *
Does your child have any particular dislikes: *
Information from School/College
We strongly recommend that you ask your child's school to complete our School Questionnaire. This provides us with an invaluable insight into your child's current school performance and attainments, as well as the information you provide.

Please note that if your child is in Years 9-13 and access arrangements in exams are being considered, it is essential that you contact the school/college to discuss the situation.
Access Arrangements in exams
Do you hope to use the report as evidence for obtaining access arrangements or exam concessions: *
If yes, please read the following statement carefully.
Using the assessment report as evidence for obtaining access arrangements or exam concessions.
There is no guarantee of evidence for an access arrangement being found during any assessment. Each assessor will refer to the most recent access arrangements guidance and make recommendations, if and when appropriate for the school/college to consider.

If you wish to use the assessment report as evidence for obtaining access arrangements in exams, please remember that it is essential that your child's school/college is consulted before the assessment process begins. Access arrangements and exam concessions are entirely the responsibility of the school/college and certain forms have to be completed within a rigid time scale.

Therefore, before booking an assessment with us, please: Consult your child's school/college.

If the school/college agrees for you to proceed with the assessment to investigate access arrangements or exam concessions, please ensure they complete our School Questionnaire and include their their full contact details. By supplying this information you agree to us contacting and speaking with them directly regarding any access arrangement and relevant paperwork should an urgent need arise.

Once we receive their completed questionnaire, it will be reviewed by one of our professionals who will then authorise the relevant assessment to be booked and you will be contacted.
Please confirm you have read and understood the statement on access arrangements above: *
Please be aware that most assessments take place at the Helen Arkell Dyslexia Charity near Farnham in Surrey. We also have hubs at John Keats School London, Sarum College, Salisbury and Prama House, Oxford ( where we assess less frequently. Please indicate which location you would prefer. *
Required
How did you hear about the Helen Arkell Centre (please give specific details in 'Other' if possible):
Would you like to sign up to receive our Helen Arkell newsletter and emails? (You can unsubscribe at any time, we will not bombard you with emails and we will not share your details with third parties):
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Additional and supporting documents:
Please send all supporting documents by email to questionnaire@helenarkell.org.uk or by post to Helen Arkell Dyslexia Charity, Arkell Lane, Frensham, Farnham, Surrey. GU10 3BL
Permission for sharing of information
When you come for an assessment at the Helen Arkell Dyslexia Charity (HADC) personal data (including name, date of birth, address) will be collected. This will be retained by HADC, stored securely in line with the Data Protection Act 2018 (GDPR) and not shared. We are totally committed to protecting your information and using it responsibly. Please do read our Privacy Policy for full details regarding the use and storage of your information. https://www.helenarkell.org.uk/about-us/privacy-policy.php

You will see from our Privacy Policy that, as a charity with a mission that includes helping people with dyslexia and educating the public, we are always looking for ways to monitor and improve the value of our work. Information about the impact of identification of dyslexia/specific learning difficulties (SpLDs) upon the person, the family and the work environment is essential. By sharing information and experiences with the wider community, we can ensure a greater understanding, which in turn helps all of us who have dyslexia. To help us with this, we would appreciate it if you would give your permission for us to use an anonymised version of your questionnaire/report (i.e. with your personal data removed), for research purposes.

I agree that my questionnaire, assessment information and report may be stored for the long term. This could be used, anonymised, without further permission given by me, to provide appropriate support and as part of information for research purposes, shared anonymously with the following:

• School learning support departments and teachers
• Educational Psychologists
• HR departments and employers
• Research projects

For research purposes, only anonymised questionnaires and assessment data will ever be shared. If shared, this data will be assigned a unique code number, and it would be very difficult to identify individuals from this information. This anonymised data may be used in research and the findings may be published in scientific journals and used in lectures to other scientists, students and the general public. Care will be taken to ensure that individuals are not identified in lectures or publications.
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