Pre 16 Background Screening Questionnaire
Please be aware that the assessments take place at Phoenix Dyslexia Consulting, Uxbridge UB8 1EX
This form takes approximately 30 minutes to complete. It is important that this questionnaire is completed as fully as possible. If you want, you can ask friends and family their opinion as well. This will enable us to support you in the most effective way.

PLEASE DO NOT PRINT THIS FORM. Complete online and submit, it will be sent to us for analysis.
Phoenix Dyslexia Consulting respects personal information as very important and therefore ensures that personal information is treated lawfully and correctly. We will never share or sell your information on. If you choose not to progress to the assessment stage, we will destroy any information you have sent us.
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.
Email address *
Please confirm you understand the above information and are happy for your information to be held by Phoenix Dyslexia Consulting for the purposes of the assessment, * *
Please confirm you understand 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. *
Required
Child's Full Name *
Child's Age *
Date of birth *
MM
/
DD
/
YYYY
Gender *
Title of Parent Completing the Screening
Parent's Full Name *
House or Flat Number *
Street Name *
City or Town *
Postcode *
Best telephone number to contact you on *
Email address *
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