Screening 2 : Enquiry

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Screening Service Enquiry : Child screening only

Regrettably, our ADULT screening service remains suspended due to reduced volunteer availability. This form is for CHILD screening enquiries only please.

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.

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Your Name* This field is required.

Title

First Name

Last Name

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Telephone Number* This field is required.

Area Code

Phone Number

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E-mail

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Enquiry Date

Date

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When is the best time to contact you by telephonePlease select all that apply

Mornings

Afternoons

Evenings

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Name of person to be screened* This field is required.

Title

First Name

Last Name

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Date of birth of person to be screened* This field is required.

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Days

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Age of person to be screened

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Although our CHILD screening service has now resumed, regrettably our ADULT screening service remains suspended due to reduced volunteer availability.

This form is for CHILD screening enquiries only.

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When would you prefer your screening to take place* This field is required.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 - Please select all that apply

Mornings

Afternoons

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Click to confirm* This field is required.

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.

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Click to authorise* This field is required.

I am the parent/guardian of the child being screened

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

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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.

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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