Request for Diagnostic Assessment

Parent's Name * Required

Email * Required

Phone * Required

Address * Required

Client / Student's Name * Required

Client's Birthday * Required

Investigating * Required

I am interested in having a diagnostic investigation into the following SpLD(s)

Do you agree to our T&Cs found at * Required

https://spldassessment.com/specialist-assessment-terms-and-conditions/

Yes

Why are you requesting this investigation? * Required

School Name

School Year

Is there any further information that we should be aware of?

Sometimes we get late notice cancellations due to illness etc. If that happens and we already have all your background information would you like to be considered for taking those earlier appointments?

Yes please

Name of person agreeing to contract * Required

I understand that a Diagnostic Assessment is intended to confirm whether an individual has dyslexia and / or dyscalculia or not. It provides a clearer picture of the person’s strengths and weaknesses and their individual cognitive profile.

The Diagnostic Assessment will be followed by a written report. This report will provide evidence of the individual’s profile (if the individual has been confirmed as having dyslexia and / or dyscalculia), signposting to other organisations or further assessments for specific learning difficulties (if required), and will include some recommendations about how to support the individual in the context of their study and/or day-to-day life.

The Diagnostic Assessment will be carried out out by a qualified specialist teacher/assessor holding an Assessment Practising Certificate (APC) issued by PATOSS.

I agree to pay a non-refundable deposit of 50% upon booking, full payment will be made prior to release of the final report.

I understand that I will need to complete questionnaires and requested background information, the links to these forms will be emailed to the address provided above. I will complete these forms no less than three weeks before the first testing appointment along with permission to contact other professionals such as the student's school so they can provide background information together with historic and current attainment levels.

Data is kept electronically. Only the data needed to complete the assessment and / or tuition is kept. Anonomised data may be used for academic purposes. Data will not be passed onto third parties without express written instructions and will be destroyed within 12 months of no longer being a client of SpLD Assessment (subsidiary of Southampton Tuition Centre).

Please enter the name of the person requesting this investigation below as your electronic signature: