Adult Assessment Questionnaire
If you are between 16 and 18 years old and have not been assessed for dyslexia previously, please could you complete the Family Questionnaire instead of the Adult one, to help us to help you better.

Please scroll down to answer questions.
Adult Assessment Questionnaire
If you find this form difficult you can phone us and we will help you fill it in.
Please complete this form as fully as you can and press the Submit button at the end to return it to the Charity. It will help us to help you. The answers are entirely CONFIDENTIAL to the Charity's Staff and other Professionals directly concerned with you.

We are totally committed to protecting your information and using it responsibly. Please read our Privacy Policy carefully to understand how we collect, use and store your information. https://www.helenarkell.org.uk/about-us/privacy-policy.php
Your Details
Please complete the section below as thoroughly as possible, your phone numbers, email address and home address will only be used to contact you by the Helen Arkell Centre. Details will remain confidential.
First Name: *
Your answer
Surname: *
Your answer
Date of birth: (please use this format "1st September 2006") *
Your answer
Male/Female:
Title:
Tick as appropriate
Your full address (including town): *
Your answer
Your Postcode: *
Your answer
Preferred telephone contact number: *
Your answer
Email Address:
Your answer
If you would like us to contact someone else to arrange the assessment for you please give details below (e.g. if you are a student or young adult and you'd like your parents to be involved, or for any other reason)
Your answer
Their name
Your answer
Relationship to you
Your answer
Their contact number
Your answer
Their email address
Your answer
Family Background
Learning is complex, it is helpful to know if other family members have struggled in these areas. It would be good to check some of this with your parents/carers if you can.
Have any of your family members had problems with any of the following:
Which Relatives?
Your answer
What languages are spoken at home?
Your answer
Is English your first language?
Your answer
If not, what is your first language, and how long have you spoken English?
Your answer
Early History and Health
This section is important - please answer each question (You may need to check some of this with your parents/carers)
Did your speech and language develop well: *
Did you receive speech therapy: *
If you did receive speech therapy, please give details:
e.g. Were you assessed? How long did you receive therapy for?
Your answer
Have you had any accidents that required hospital treatment: *
If Yes, please give details:
Your answer
Please give information regarding any serious illnesses or medical conditions that we should be aware of? *
Your answer
Have you had any mental health problems?
If Yes, please give details
Your answer
Are you currently taking any medication: *
If Yes, please give details
Your answer
Do you suffer from any of the following: *
Required
When was your most recent eyesight test? ( If it was more than 2 years ago, it is a professional requirement that an eye test is carried out before the assessment takes place) *
Your answer
What was the result? *
Your answer
Do you have any visual difficulties?
If Yes please describe
Your answer
Is your hearing normal? *
If No, please give details
Your answer
Have you suffered with ear infections (including as a child)? *
Have you ever had grommets inserted in your ears? *
Have you had your tonsils/adenoids removed? *
Have you had any problems with coordination or balance (including as a child)?
If Yes please describe
Your answer
Are you left or right handed?
Educational History
Past Schools/Colleges attended:
Please list the school/college names, the dates you attended and whether it was a state or independent school/college
Your answer
Were there reasons for changing schools, other than age:
If Yes, please give details:
Your answer
Have you ever had extra tuition or therapy: *
Please tick all that apply
Required
If Yes, to the above, please give details of how long and how often the support was received:
e.g. 1 hour per week for 2 years
Your answer
Have you ever been assessed for dyslexia/dyspraxia? e.g. by an educational psychologist or specialist teacher or school *
If Yes, please give details (type of professional, when and results):
Your answer
Do you have a copy of previous reports:
If Yes, we will need to see it so please send a copy to the Helen Arkell Centre:
Were your difficulties ever recognised in school?
If Yes, please give details
Your answer
Have you been to a special school?
If Yes, please give details
Your answer
Have you ever received extra time in examinations? Or any other access arrangements such as a reader, use of a computer or a scribe? *
If Yes, please state which arrangements and give details:
Your answer
Have you ever had a Statement of Special Educational Needs or an EHCP?
If Yes, please give details:
Your answer
Have you passed exams:
Please give details:
e.g. "O" levels, GCSE, "A" levels, RSA, City & Guilds etc
Your answer
Have you ever failed exams:
Please give details:
e.g. "O" levels, GCSE, "A" levels, RSA, City & Guilds etc
Your answer
Your Current Situation
What is your current situation?
e.g Student/Employed/Unemployed/other
Your answer
If you are currently in full-time education, what are you hoping to do when you leave education? (e.g. apply to university/find work)
Your answer
If you are employed please provide details:
Your answer
Please list any jobs you have had:
Your answer
If you are not in work, what work or training are you interested in?
Your answer
Do you have problems with: *
Yes
No
Reading
Understanding what you read
Organisation
Spelling
Written work
Memory
Note taking
Writing speed
Learning information
Numbers
How do any of the above difficulties affect work, training, or education? *
Your answer
What are your concerns and views of these problems? *
Your answer
What are the questions you hope the assessor can answer? *
Your answer
What are your reasons for having an assessment?
Your answer
Do you have special interests/hobbies:
If Yes, please describe:
Your answer
Do you have any particular dislikes:
If you have had help from someone else to complete this questionnaire please tick here. *
Required
Please be aware that most assessments take place at the Helen Arkell Dyslexia Charity near Farnham in Surrey (GU10 3BL). We also have hubs at John Keats School (SE16 3FN), Sarum College, Salisbury (SP1 2EE) and Prama House, Oxford, OX2 7HT, where we assess less frequently. Please indicate which location you would prefer. *
Required
Additional and supporting documents
Please send all additional or supporting documents to questionnaire@helenarkell.org.uk
Important Notice
The Helen Arkell Dyslexia Charity is a registered charity in England and Wales (1064646). Whilst great care is taken in all matters, the Charity cannot accept any liability or responsibility for any advice given by the professionals to whom the Charity refers you or their other acts or neglect.

We are totally committed to protecting your information and using it responsibly. Please read our Privacy Policy carefully to understand how we collect, use and store your information. https://www.helenarkell.org.uk/about-us/privacy-policy.php

If you provide your e-mail address the Helen Arkell Dyslexia Centre may contact you with information by email.
Please tick to confirm you have read and understand this notice: *
Required
Would you like to sign up to receive our monthly 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.) *
How did you hear about the Helen Arkell Centre (please give specific details in 'other' if possible): *
Required
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.

Please tick as appropriate
Signed:
Your answer
Date:
Your answer
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