STC Registration Form

Request for a SpLD Screening

Dyscalculia and / or Dyslexia
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 screen for the following:*
Note: current price is £100 for either dyslexia or dyscalculia screening or £150 for both conditions.
Why are you requesting a screening?
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 screening is intended to indicate whether an individual might benefit from a full diagnostic investigation into dyslexia and / or dyscalculia or not. It is not a diagnosis of a specific learning difference.

The screening 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 fee upon booking, prior to attending for the screening.

Should the recommendation be to conduct a full diagnostic investigation then if this is undertaken within 6 months of this screening the fee for this screening will be deducted from the fee for the diagnostic investigation.

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 6 months of no longer being a client of Southampton Tuition Centre.
Please conduct a screening as per details above*

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signature
Date*

DayMonthYear
Date
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Request for a SpLD Screening