Adult Assessment Questionnaire
Please be aware that assements take place at the Helen Arkell Dyslexia Centre, Frensham, near Farnham in Surrey, GU10 3BL. 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 the Centre will help you. Please complete this form as fully as you can and press the Submit button at the end to return it to the Centre. It will help us to help you. The answers are entirely CONFIDENTIAL to Centre Staff and other Professionals directly concerned with you.

Helen Arkell Centre regards personal information as very important and therefore ensures that personal information is treated lawfully and correctly. To this end Helen Arkell Centre fully endorses and adheres to the principles of Data protection, as detailed in the Data Protection Act 1998. For further details of Helen Arkell Centres Data protection policy please visit www.helenarkell.org.uk/privacy-and-cookies.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 Address: *
Your answer
Your Postcode: *
Your answer
Preferred telephone contact number: *
Your answer
Email Address:
Your answer
Family Background
Learning is complex, it is helpful to know if other family members have struggled in these areas
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
Early History and Health
This section is important - please answer each question
Did your speech and language develop well: *
Did you receive speech therapy: *
If you did receive speech therapy.
e.g. Were you assessed? How long did you recieve therapy for?
Your answer
Have you had any accidents that required hospital treatment: *
If Yes, please give details:
Your answer
Do you suffer from any of the following: *
Required
Please give information regarding any illnesses or medical conditions that we should be aware of? *
Your answer
Are you currently taking any medication: *
If Yes, please give details
Your answer
When was your most recent eyesight test? (please enter date in this format (day/month/year) *
MM
/
DD
/
YYYY
Is your eyesight normal: *
If No, please give details
Your answer
Is your hearing normal: *
If No, please give details
Your answer
Have you suffered with ear infections: *
Have you ever had grommets inserted in your ears: *
Have you had your tonsils/adenoids removed: *
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:
Have you ever received extra time, or any other access arrangements in examinations: *
If Yes, please state which arrangements and give details:
Your answer
Have you ever had a Statement of Special Educational Needs:
If Yes, please give details: *
Your answer
Were your difficulties ever recognised in school: *
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 present job or occupation:
Or if you are currently in full-time education, what are you hoping to do when you leave?
Your answer
If you are currently a student, what are you hoping to do when you leave education:
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
Do you have special interests/hobbies:
If Yes, please describe:
Your answer
Do you have any particular dislikes:
If Yes, please describe:
Your answer
Additional and supporting documents
Please send all additional or supporting documents to questionnaire@helenarkell.org.uk
Important Notice
The Helen Arkell Dyslexia Centre is a registered charity. Whilst great care is taken in all matters, the Centre cannot accept any liability or responsibility for any advice given by the professionals to whom the Centre refers you or their other acts or neglect.

The Centre may, in its absolute discretion and after the appropriate permissions have been obtained, maintain, for its administrative and quality assurance purposes only, a confidential file of records relating to you including a copy of this Questionnaire and any reports. The Centre is at liberty to destroy such files or to charge a reasonable sum to retrieve for you any such files that have been retained.

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
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