Screening : Enquiry

Screening Service Enquiry

Completing this form does not constitute a confirmed booking. This form is for enquiry purposes only.

Please note that our screening service is not appropriate for tribunals or Disabled Students' Allowances.

The following information is needed to process your enquiry, and to provide the services you will receive. We will hold your personal data on our systems for no longer than is necessary.

Your Name *

Title First Name Last Name

Telephone Number *

Area Code Phone Number

E-mail

Enquiry Date

Day Month Year

When is the best time to contact you by telephone *

Please be aware that our screening service is operated entirely by unpaid volunteers. We will endeavour to respond to your enquiry within 5 days of submission, but this may increase at times of high demand. We thank you for your patience.

Please provide us with the following details about the candidate to be screened.

Name of person to be screened *

Title First Name Last Name

Date of birth of person to be screened *

Day Month Year

Days

Age of person to be screened

Screenings are arranged by mutual agreement between yourself and the Screening Co-ordinator. However, it would be useful if you could indicate your day/time preferences for the screening.

Click all that apply

Weekdays Weekends Mornings Afternoons Evenings

Click to confirm *

I understand that this is a computer screening to determine the probability of dyslexia, and is not a full assessment. I also understand that any advice offered on the basis of the results is only suggested future action that I may choose to take.

Click to authorise *

I am the parent/guardian of the child being screened I am NOT the parent/guardian of the child being screened

Each screening costs £40 (a 50% discount can be offered to those who provide proof of financial hardship).

Payment will be requested in advance of the screening, once your booking has been confirmed.

Helpline Number 0300 999 1800

Community House, South Street, Bromley, Kent BR1 1RH

info@dyslexiawise.co.uk

www.dyslexiawise.co.uk

The Dyslexia Association of Bexley Bromley Greenwich and Lewisham is a local association supporting dyslexics in the community, recognised by the British Dyslexia Assocation.

A company limited by guarantee no. 5725573 - English Charity No. 1114382