Adult Assessment Questionnaire

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  • Adult Assessment Questionnaire

    If you find this form difficult the centre will help you. Please complete this form as fully as you can and 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. To fill in the Y/N boxes use an X

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  • For completion by parent or guardian

    If you would like any help in completing this form, please contact the Centre. It is important that this questionnaire is completed as fully as possible; this will enable us to support your child in the most effective way. The information given is entirely confidential to Centre staff and other professionals directly concerned with your child. 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.
  • Parents’/Guardians’ details for correspondence

  • Name and address of the parent(s) /guardian(s) to whom the assessment report should be sent (if different from above). The report will be sent only to name person(s).
  • If you are in the workplace, or unemployed and would like help with skill development please complete this form as fully as you can and return it to the Centre. It will help us to help you. The answers are entirely CONFIDENTIAL to Centre Staff and Professionals directly concerned with you.

    If you find this form difficult to complete the Centre will help you.
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  • Medical History:

    Please give information regarding any illnesses or conditions that we should be made aware of
  • Important Notice

    Whilst great care is taken in all matter, the Centre cannot accept liability or responsibility for any advice given by the professionals to whom the Centre refers the child/adult (assesse).

    The Centre may, in its absolute discretion and after the appropriate permissions have been obtained, maintain, for its administrative purposes only, a confidential file of records relating to the assesse 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 any such files that have been retained.

    If you provide your e-mail address Dyslexia Nigeria may contact you periodically with information and news. Any e-mail sent by Dyslexia Nigeria will provide the option to be removed from the e-mail mailing list.
  • Your completion and return of this questionnaire is your acknowledgement that you have read, understood and accept the terms of this notice and that you agree/do not agree (delete as appropriate) to The Centre maintaining a confidential file.
  • Information is being gathered to clarify this child’s learning, emotional and/or behavioural needs. Information from the current school will be very useful and help to provide a wider context in which to place these needs. Your support is therefore appreciated.

    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.
  • All information given will be treated confidentially.

  • YearEnglishMathsScience 
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  • Current subject performance in relation to peer group:

  • Does the child have any difficulty with:

  • If the child has a Statement of Educational Needs, please attach a copy of the most recent Annual Review or other relevant information to screenings@dyslexianigeria.com
  • Your questionnaire will remain the confidential property of the parents, so please return your response to them. Thank you for taking the time to complete this questionnaire. If you provide your e-mail address Dyslexia Nigeria may contact you periodically with information and news. Any e-mail sent by Dyslexia Nigeria provides the option to be removed from the e-mail mailing list.
  • COURSE DETAILS

  • Terms & Conditions

    • Courses will run with a minimum of 10 participants and a maximum of 30 (unless otherwise stated).
    • Places will be allocated on a first come first served basis.
    • Cancellations by the course participant, up to five working days before the date of the course, will be chargeable.
    • The charge for each course is indicated on the short course flyer or information sheet.
    • Full refunds will be paid in the event of course cancellation by Dyslexia Nigeria.
    • Confirmation of your booking will be sent one week before the due course date.

    I agree to abide by the terms and conditions stated above
  • Contact Information

  • Personal Information

  • Availability

  • Interests

  • Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including hobbies or sports.
  • Summarize your previous volunteer experience.
  • Person to Notify in Case of Emergency

  • Agreement and Signature

    By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.
  • Our Policy

    It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.

    Thank you for completing this application form and for your interest in volunteering with us.