Dyspraxia Pre-Questionnaire

This form takes approximately 20 minutes to complete and some of the questions are compulsory. Please scroll down to answer questions. Press Submit once you have completed the questionnaire.

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

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 us. It will help us to help you. The answers are entirely CONFIDENTIAL to Develop Us and other Professionals directly concerned with you.

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.
UK DCD Descriptor
Developmental Coordination Disorder (DCD), also known as Dyspraxia in the UK, is a common disorder affecting movement and coordination in children, young people and adults with symptom present since childhood.

DCD is distinct from other motor disorders such as cerebral palsy and stroke and occurs across the range of intellectual abilities. This lifelong condition is recognised by international organisations including the World Health Organisation.

A person’s coordination difficulties affect their functioning of everyday skills and participation in education, work, and leisure activities. Difficulties may vary in their presentation and these may also change over time depending on environmental demands, life experience, and the support given. There may be difficulties in learning new skills.

The movement and coordination difficulties often persist in adulthood, although non-motor difficulties may become more prominent as expectations and demands change over time.

A range of co-occurring difficulties can have a substantial adverse impact on life including mental and physical health, and difficulties with time management, planning, personal organisation, and social skills.

With appropriate recognition, reasonable adjustments, support, and strategies in place people with DCD can be very successful in their lives.
Are you completing this form on behalf of someone else? *
If you are completing this form for someone else, what is your name and the relationship to the person being assessed?
Details of Booking
Name *
Home Address *
Contact Telephone number *
Contact Email *
Please indicate your preferred contact method(s) *
Required
Name and address to whom the report should be sent if different from above. The report will only be sent to named persons *
Date of birth *
MM
/
DD
/
YYYY
Age *
Gender *
Are there any dates that you are NOT available in the next 2 months? *
How would you like to pay? *
Terms and conditions
I understand that on receipt of my booking pack containing the required completed documents, Develop Us will contact me to agree an appointment date and time for the assessment.

I agree that the Develop Us reserve the right to charge a cancellation fee equivalent to 100% cost of the assessment for assessments that are cancelled within 48 hours of the agreed assessment date.
Do you agree with our terms and conditions? *
Booking a Diagnostic assessment
• Develop Us will act as a liaison between the assessor and the client for the purposes of booking the assessment.

• Develop Us reserves the right to change the assessor allocated if the assessor should become unavailable for any other reason.

• In order to book the assessment your personal information and the information contained within the booking pack will be passed onto the assessor in order for them to carry out the assessment.
Privacy Policy
• Develop Us is committed to protecting the privacy of individuals. Accordingly, all personal data collected will be subject to our Privacy Policy. For more information please see our website.

• Following the assessment and the compilation of the final assessment report all client questionnaires, all raw data test sheets and all other personal data will be permanently deleted/destroyed.

• Your final assessment report will be held by Develop Us for 7 years [within your customer record file]. During this time you will be able to ask for an electronic copy of the report Please note there may be an administration charge for this. We would therefore strongly recommend that you keep a copy of your report securely. After this time Develop Us will not be able to supply you with a copy of your report.

• Should you require a copy of your assessment report, your report to be permanently deleted; or for changes/corrections made to it before this time; or to make a complaint, please notify us at: info@developus.wales
How your information will be used
From time to time we may like to send you information about our own products and services that you might be interested in, by post, telephone, email and SMS. We will not pass your information on to any organisation external to Develop Us. If you agree to being contacted in this way.
From time to time we may like to send you information about our own products and services that you might be interested in, by post, telephone, email and SMS. We will not pass your information on to any organisation external to Develop Us. If you agree to being contacted in this way, please tick the relevant boxes to indicate all of the means by which you would like to be contacted. *
Required
Terms and Conditions
Payment details:
• Payment details must be received before a booking can be processed.

Cancellation policy:
• Cancellation by the Client or Main Contact
• All changes and cancellations must be notified in writing to: info@developus.wales
• Cancellation charges will be applied as follows:
• Cancellation/reschedule within 14 days of a booked session = 50% of fee due;
• Cancellation/reschedule within 24 hours of a booked session = 100% of fee due.

• Cancellation by Develop Us
• In the event that severe weather or any other emergency results in the cancellation of a session, Develop Us will endeavour to give clients a minimum of 24 hours’ notice* and to reschedule the assessment
• *Please note that it is the client’s responsibility to provide Develop Us with an emergency contact number at which they will normally be available.
I agree to abide by the terms and conditions as laid out above *
Signature *
How did you hear about Develop Us? *
Required
Access Arrangements
Following recent changes to the Joint Council for Qualifications (JCQ) guidance for Access Arrangements 2017/18 please be aware of the following:

If you require the assessment that you are booking with Develop Us to be used as part of an application for Exam Access Arrangements, usually GCSEs or A Levels, e.g. extra time in exams, a reader or a scribe, etc. then it will be necessary for either you or Develop Us on your behalf (with your written permission) to contact your educational establishments Special Educational Needs Coordinator (SENCO) prior to the assessment as this is now a JCQ requirement.

“7.3.6 A privately commissioned assessment carried out without prior consultation with the centre cannot be used to award access arrangements and cannot be used to process an application using Access arrangements online.
The SENCO must complete at least a ‘skeleton’ Section A of Form 8 prior to the candidate being assessed (Section C of Form 8).” JCQ - Adjustments for candidates with disabilities and learning difficulties Access Arrangements and Reasonable Adjustments 2017/18

If you would prefer not to contact the SENCO or think that you might experience difficulties with this then please do contact us to discuss your options and the implications of this prior to booking an assessment.
CONFIDENTIAL PRE-ASSESSMENT QUESTIONNAIRE
Country of Birth *
Date moved to the UK
MM
/
DD
/
YYYY
Are you adopted? *
Briefly explain why you wish to be assessed. *
Employment / Continuing Education
Are you currently in work? *
If you are employed, what is the name of employer?
What is your current job title / role?
Please give details of any previous work you have done.
Are you currently taking a course of study? *
lf you are studying, what are you studying and where?
How often do you attend?
Clear selection
How long is the course?
How far into your course of study are you?
Have you taken any other courses since leaving school? If yes, please give details below:
Developmental History
Were you delivered at full term and a normal delivery? *
Did you reach all the normal developmental milestones? E.g. Walking, talking, riding a bike? *
Have you ever had any Speech and Language difficulties? *
Is there a history of ear infections, glue ear or grommets? *
Family Background
If helps us to gain more information about your family background.
Father's Occupation
Mother's Occupation
Do you have any brothers or sisters?
Clear selection
If you do have brothers or sisters, how many do you have?
Languages
Is English your first language *
If No, how long has English been spoken?
If No, what languages are spoken in the home:
If No, do 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 father ever struggled with any of the following? *
Required
Has your mother ever struggled with any of the following? *
Required
Have your siblings ever struggled with any of the following? *
Required
Have any other relatives ever struggled with any of the following? e.g. grandparents, uncles, aunts, cousins. *
Required
If Yes, which relatives?
Development
Have you ever had any problems with: *
Yes
No
Clarity of speech
Understanding spoken language
Self expression
If any of these are ongoing, please give details
Have you ever had a speech, language and communication assessment or therapy? *
If Yes, please send copies to info@developus.wales
If a report is not available, please give details
Medical History
Information about your health is important.
Has you had any of the following? *
Please tick all that apply
Required
Please give details of any accidents or any hospitalisation you have had
Please give details of any illness or conditions that the assessor should be made aware of
Do you suffer from any of the following? *
Please tick any that apply
Required
Are you on any medication? *
If yes, please give details
Are you normally healthy? *
If no, please give details
Are you on a special diet, or are any foods avoided? *
If yes, please give details
Do you wear glasses? *
If yes state your prescription and ensure you bring the glasses to the assessment:
Please give details about when and where your most recent eye test was and the result: (If more than 2 years ago, it is a professional requirement that an eye test is carried out before the assessment takes place)
Do you experience any visual difficulties when reading and writing? *
Yes
No
Words moving on the page
Words blurring
Often losing his/her place
Other
If yes (or any similar difficulties have occurred), please give details
Have you ever consulted a vision specialist about any difficulties expressed above (e.g. Optometrist)? If so, please give details of who and when
How is your hearing? *
Yes
No
Has your hearing been tested (within the last 2 years)?
Do you have a history of ear infections?
Do you think you hears normally at the moment?
Have you ever thought you may have hearing loss?
Please give any relevant details for the above
Has you had surgery for any of the following procedures? *
Please tick all that apply
Required
Please give any relevant details for the above
Activity and behaviour
Have you ever had difficulty with any of the following? *
Please tick all that apply
In the past
Ongoing
Unsure
No
Jigsaw puzzles
Lego
Colouring/drawing
Dressing
Using cutlery
Tying shoelaces
Catching balls
Throwing balls
Climbing stairs
Cycle riding
Co-ordination
Clumsiness
Toilet training
Bed-wetting
Hyperactivity
Tantrums
Discipline
Long silences
Sleeping
Nightmares
Anxiety
Eating
Food textures
Being withdrawn
Following verbal instruction
Remembering nursery rhymes
Learning times tables
Organisation
Concentration
Please give any further information you feel is relevant
Education
Please give details of your education to date *
School(s) followed by start date and end date (or current) and whether State or Independent
Did you ever miss 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
Did you receive 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?
Did you have support in school? *
If yes, please tick all that apply
If yes, please say when (years) and how often (number of times per week)
Have you had any other therapy? *
If yes, please give details
Have you been assessed previously by an Educational Psychologist or Specialist Teacher? *
If Yes, please send a copy of the report to info@developus.wales
Have you ever been assessed previously by any other professional? e.g. Specialist teacher/Occupational therapist *
If Yes, please send a copy of the report to info@developus.wales
If Yes, please give details:
What difficulties do you currently experience?
Reading *
Spelling *
Writing *
Mathematics *
Your views and concerns
What are your reasons for arranging an assessment? *
What special interests/hobbies/talents do you have? *
Do you have any particular dislikes? *
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
Following recent changes to the Joint Council for Qualifications (JCQ) guidance for Access Arrangements 2017/18 please be aware of the following:

If you require the assessment that you are booking with Develop Us to be used as part of an application for Exam Access Arrangements, usually GCSEs or A Levels, e.g. extra time in exams, a reader or a scribe, etc. then it will be necessary for either you or Develop Us on your behalf (with your written permission) to contact your educational institutions Special Educational Needs Coordinator (SENCO) prior to the assessment as this is now a JCQ requirement.

“7.3.6 A privately commissioned assessment carried out without prior consultation with the centre cannot be used to award access arrangements and cannot be used to process an application using Access arrangements online.
The SENCO must complete at least a ‘skeleton’ Section A of Form 8 prior to the candidate being assessed (Section C of Form 8).” JCQ - Adjustments for candidates with disabilities and learning difficulties Access Arrangements and Reasonable Adjustments 2017/18

If you would prefer not to contact the SENCO or think that you might experience difficulties with this then please do contact us to discuss your options and the implications of this prior to booking an assessment.
Please confirm you have read and understood the statement on access arrangements above *
Sharing Information
If applicable, are you happy for Develop Us to share assessment outcomes with the educational establishment, including results and recommendations? *
If you are happy for us to consult with your place of study, please provide the details below.
Educational institution name
Educational institution address
Main contact at the educational establishment (please include email and the role of the professional)
If applicable, are you happy for Develop Us to share assessment outcomes with your employer, including results and recommendations? *
Required
If you give consent for Develop Us to share information with your employer, please provide the business name and address, name of whom should be contacted, their email address and contact number.
Declaration Statement
I confirm that the information provided in this questionnaire is accurate. *
Date *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy