STC Registration Form

Student Name

First NameLast Name

Birth Date

MonthDayYear

Address

Street Address

Street Address Line 2

CityCounty

Post Code

School Year

School Attended

Parent / Carer(s) Name*

First NameLast Name

Parent / Carer E-mail*

Parent Mobile Number*

Alternative Phone Number (emergencies)

Please enter a valid phone number.

Please investigate for the following:*

Note: current price is £600 for either dyslexia or dyscalculia investigation with report or £800 for both conditions.

Why are you requesting a diagnostic assessment?

Please confirm that eyes have been tested within the previous 12 months

Eyes have been tested within last 12 monthsEyes will be tested prior to this educational testing

Please list any medical conditions, disabilities including allergies the student may have.

Is there any other information that you think we should be aware of?

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 Southampton Tuition Centre.

Please conduct a diagnostic assessment *

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Date*

Date

Request for Diagnostic Assessment

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