Adult (Post 16 Years)

Adult (Post 16 years)

Dyslexia Assessment

Booking Pack

Name: ………………………………………………………………….

Age andDate of Birth:……………………………………………

Please read the information sheet that accompanies this booking pack carefully as this will provide important information about the type of assessments available, the assessment process and what to expect, and answers to other frequently asked questions.

The Assessment Booking Process:

If the report is for Disabled Students Allowance (DSA) it then needs to be sent to Student Finance England.

Diagnostic Assessment – Adult (post-16)
Booking Form

Please complete this booking pack to book a diagnostic assessment. Please return the completed booking pack by email to:

BDA Office use only:
Booking Reference: / Account Code T17
Details of Booking
Name of person being assessed:
Date of birth: / Age:
Home Address :
Contact Telephone numbers:
Contact Email:
Please indicate if the assessment is to be with a Specialist Teacher Assessor OR a Psychologist:
(Please note the assessment will take up to four hours) / Tick Here
Specialist Teacher Assessor / £450.00 plus VAT @ 20% = £540.00
Psychologist / £600.00 plus VAT @ 20% = £720.00
Are there any dates that you are NOT available in the next 2 months? / Y / N
If yes, please give details:

Method of Payment:

Cheque (please make payable to the B.D.A.) / ☐ / Card (please complete details below) / ☐
Total amount to be paid: / £

Please note that payment will be taken once an assessment date has been agreed.

Credit Card Payment: please fill out the form below

Please debit my account for the amount of: / £
Card type: / Visa ☐ / Mastercard ☐ / Switch/Maestro ☐ / Delta ☐
Please provide card number & details:
For Maestro cards insert the whole of the long number which appears across the middle of the card
/ / /
Valid From Date / Valid To Date / Switch / Maestro Issue No. / Switch / Maestro
Start Date
Name as it appears on the card:
Cardholder’s signature: / Date:

Terms and conditions:

I understand that on receipt of my booking pack containing the required completed documents, BDA will contact me to agree an appointment date and time for the assessment.

I agree that the BDA 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.

Signature:
Name (print):
Date:

Please return this booking pack by email to to enable us to check the details and contact an appropriate assessor.

Terms and Conditions for Diagnostic Assessments

Booking a Diagnostic assessment:

• The B.D.A. will act as liaison between the assessor and the client for the purposes of booking the assessment.
• The B.D.A. 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:

• The BDA 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 the BDA 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 the BDA will not be able to supply you with a copy of your report.

• Should you require a copy of your assessment report [and/or the personal data in your customer record]; or for 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:

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 the BDA. 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.

PostPhone EmailSMSphone call

The BDA is committed to protecting your personal data please see our Privacy Policy on our website

If you need any further information please write to us at:

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: .
• 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 the B.D.A.
• In the event that severe weather or any other emergency results in the cancellation of a session, the B.D.A. 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 the B.D.A. with an emergency contact number at which they will normally be available.

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I agree to abide by the terms and conditions as laid out above.

Name (print): / Signature: / Date:

Please return this booking pack by email to to enable us to check the details and make provisional contact with the most appropriate assessor.

How did you hear about the BDA

Website BDA Helpline Email Hardcopy Flier social media

Recommendation Other please state ______

Locations our Assessors Cover

Some assessors will travel to you to carry out assessments, others may prefer you to come to their premises so please be aware that you may need to travel to attend an assessment. Our assessors will travel a maximum of 40 miles but you may prefer to travel further in order to go to them.

Please indicate your preferred location for your Specialist Teacher OR Psychologist assessment.

We have assessors who cover the following locations. Please note that psychologist assessments are not available in all locations.

Assessor locations / Specialist Teacher
£540.00 (inc. VAT) / Psychologist
£720.00 (inc. VAT)
Berkshire
Bishops Stortford
Bracknell
Bristol / Up to age 25
Cambridgeshire
Cheshire
Coventry
Cumbria / North West England
Derbyshire
Dorset
Essex
Glasgow
Gloucestershire
Herefordshire
Hertfordshire
Kent
Lancaster
Leicester and Leicestershire
Lincolnshire
Liverpool
London
Manchester
Middlesex
Newcastle
Norfolk
Northamptonshire
Northumberland
Nottingham
Oxfordshire
Scotland (within an 80-mile radius of Pitlochry)
Scotland (Northern mainland)
Sheffield / Up to age 25
Shropshire
Somerset
Staffordshire
Surrey
Wales (South and South West)
Warrington
Warwickshire
West Midlands
West Sussex
Wiltshire
Worcestershire
Yorkshire (North)
Yorkshire (West)

CONFIDENTIAL PRE-ASSESSMENT QUESTIONNAIRE

For adults (post- 16yrs)

Full Name: / Age:
Date of Birth:
Email address:
Home address:
Contact Tel No: (mobile) / (work)

Employment / continuing education

Are you currently in work? / Yes / No
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? / Yes / No
lf YES, what are you studying?
Where?
Part time / Full time?
Have you taken any other courses since leaving school?
If YES, please give details below: / Yes / No
College / University / Date / Course / Qualification gained

School History

Which secondary schools did you attend?
What subjects were you good at?
How old were you when your difficulties were first noticed?
Did you have a good relationship with your teachers? / Yes / No
Did you work as hard in school as you might have done? / Yes / No
Did you have to work harder in order to keep up with the others in your class? / Yes / No
Did you have any difficulties at school with any of the following?
Reading / NO / SLIGHT / MODERATE / SEVERE
Spelling / NO / SLIGHT / MODERATE / SEVERE
Writing / NO / SLIGHT / MODERATE / SEVERE
Mathematics / NO / SLIGHT / MODERATE / SEVERE
Essays / NO / SLIGHT / MODERATE / SEVERE
Revision / NO / SLIGHT / MODERATE / SEVERE
Sport & games / NO / SLIGHT / MODERATE / SEVERE
Did you have any specialist help at school? / Yes / No
If YES, please give details, (e.g. Teaching assistant, extra time in exams, Statement/EHCP, specialist tuition)
Was your schooling disrupted in any way? / Yes / No
At what age did you leave school?
Have you ever seen any other specialists (e.g. speech specialists) or been assessed for learning difficulties such as dyslexia? / Yes / No
lf a written report was given can you let us have a copy? / Yes / No

Background Information

ls your vision within normal limits? / Yes / No
lf NO, please give details of problem:
ls your hearing within normal limits? / Yes / No
lf NO, please give details of problem:
Have you ever suffered from any serious illnesses? / Yes / No
lfYES, please give details:
Do you take any regular medication that may be relevant? / Yes / No
lfYES, please give details:
Did you have any problems reaching developmental milestones e.g. Learning to walk, tie shoelaces, riding a bike etc.? / Yes / No
lf YES, please give details:
Were any other languages spoken at home? / Yes / No
If YES, please give details:
Have any other family members experienced difficulties with spelling / reading / learning? / Yes / No
If YES, please give details:
Are there any situations when you do not feel confident?

Current Difficulties

ln day to day experiences at work, or on any courses you have taken, have you had difficulties with any of the following:

Communication - do you:
Find it difficult to think of the words to express what you are thinking? / Yes / No
Have difficulties saying long words or words containing particular sounds? / Yes / No
Can you give examples:
Lose track of what you want to say, or what other people are saying? / Yes / No
Sometimes find you have completely misinterpreted what you have been asked? / Yes / No
Sometimes struggle to say what you mean? / Yes / No
Have difficulty following the conversation in group discussions? / Yes / No
Get confused or freeze up if you have to speak or read aloud in public? / Yes / No
Sometimes find it difficult to take telephone messages and pass them on accurately? / Yes / No
Organisation - do you have problems with:
Planning ahead? / Yes / No
Organising yourself? / Yes / No
Prioritising your workload? / Yes / No
Meeting deadlines? / Yes / No
Working under pressure of time (e.g. in examinations)? / Yes / No
Do you put off starting tasks until the last minute? / Yes / No
Do you get confused over dates and times and miss appointments? / Yes / No
Memory and Concentration:
Do you have difficulties remembering instructions/new information? / Yes / No
Do you often lose concentration? / Yes / No
Did you find it difficult to learn your multiplication tables? / Yes / No
Do you sometimes lose track of where you are in a task and have to start again? / Yes / No
Do you find that you experience eye strain when looking at a computer screen for extended periods? / Yes / No
Does writing tend to look blurred or move about on the page? / Yes / No
Do you find it hard to remember sequences of letters or numbers such as telephone numbers or car registrations? / Yes / No
Literacy - do you have problems with:
Taking notes, e.g. at meetings or lectures? / Yes / No
Understanding what you have read? / Yes / No
Transferring information from one source to another? / Yes / No
Producing written reports, essays or other lengthy documents? / Yes / No
Proofreading your written work? / Yes / No
Summarising information? / Yes / No
Identifying key points when faced with large quantities of information? / Yes / No
Filling in forms or writing cheques correctly? / Yes / No
Do you avoid writing in front of others? / Yes / No
Do you feel your work contains a large number of spelling errors? / Yes / No
Do you miss-spell ‘easy’ words when filling in forms in front of others? / Yes / No
Do you miss out little words or the endings of words? / Yes / No
Do you sometimes muddle up words in sentences so that they don’t make sense or are grammatically incorrect? / Yes / No
Do you write long, rambling sentences? / Yes / No
Do you tend to write down everything as it comes into your head? / Yes / No
Do you avoid using words you cannot spell? / Yes / No
Do you miss out full stops, commas and other punctuation marks? / Yes / No
Orientation:
Do you have difficulty telling left from right? / Yes / No
Do you find it hard to remember directions? / Yes / No
Do you have difficulties reading road signs especially when driving? / Yes / No
ls map reading, or finding your way to a strange place confusing? / Yes / No
Arithmetic - do you:
Tend to forget mathematical operations that are used infrequently? / Yes / No
Find it hard to calculate sums in arithmetic without a calculator? / Yes / No
Find it difficult to do calculations in your head? / Yes / No
Coordination and Dexterity - do you:
Have poor coordination? / Yes / No
Find it difficult to learn how to do practical tasks? / Yes / No
Find it difficult to work with small tools or components? / Yes / No
Have difficulties in using a keyboard or mouse? / Yes / No
Often drop things, or bump into things? / Yes / No

Further Information

Please summarise your difficulties and say if there is anything you would like this brief intervention to help you with in particular.
Please include any information which you feel may be relevant.
Signed: / Print name:
Dated:

Checklist of Information Required for Booking:

1. Completed booking form

1. Assessment locations – identified the preferred type and location of assessment

1. Completed questionnaire for adults

1. Payment information/payment

Please note we cannot process bookings without having received all of the completed documentation and payment details.

Delays in returning documents/payment details will result in a delay in booking the assessment.

Email this completed booking pack to

British Dyslexia Association, Unit 6a Bracknell Beeches, Old Bracknell Lane, Bracknell, RG12 7BW

Tel: 0333 405 4555 (select Option 2 for the Assessments Department), Email:

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