Dyslexia Assessment Registration Form

Dyslexia Assessment Registration Form

Thank you for choosing SPACE for your child's dyslexia assessment. A full assessment can last up to 4 hours and takes place in your child’s school or home. Our assessors are qualified, APC registered assessors with a wealth of experience in education, schools and colleges. Each report will identify your child’s strengths and difficulties and include education advice or recommendations for onward referrals (if needed). Recent eye tests and hearing checks are essential. If you are unsure if this assessment is right for your child, contact services@spaceherts.org.uk. Please note an assessment does not guarantee a diagnosis.
Please note: Bookings are currently being taken for Autumn 2026. Availability is limited and booking is strictly on a first come, first served basis.

We anticipate high demand, and will do our best to offer an assessment in the Autumn term to everyone who registers. However, there may be instances where this is not possible. If this happens, then you will be contacted and prioritised as soon as possible.

Once your booking form is received, a member of the SPACE team will contact you within 4 weeks via email with the name and availability of the most suitable assessor. Once confirmed, we will send an invoice for the amount of £565.
Which area of Hertfordshire do you live? This helps us allocate the right assessor for you
Your name

First NameLast Name
Child's name

First NameLast Name
Date of birth

DayMonthYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Email
example@example.com
Phone Number

Area CodePhone Number
Current school (If Home Educated please write 'HE')
Any medical conditions or diagnosis (ADHD, ASD, DCD, Speech and Language Difficulties, Global delay, Moderate/Severe Learning Difficulties, genetic or chromosome conditions, hearing loss, visual difficulties etc)? Please give details.
Reason for wanting a dyslexia assessment
What support has your child had to help them with their literacy difficulties (either from yourself, school or a tutor)?
Other information (e.g. the impact of other neuro-divergent conditions, need for reasonable adjustments in an assessment, EHCP details, history of dyslexia in the family, your child's preferences, interests and strengths etc.)
The following questions provide information on your child's visual history. A child's sight might be fine, but the way they process visual information may need investigating before an assessment. If this is the case, we will notify you
Date of last sight test with an optician/optometrist
If your child has not had a sight test within the last 12 months, please confirm that their sight will be tested before the assessment takes place
Has your child been prescribed and advised to wear any optical prescription lenses (eg glasses or contact lenses?
Are these required for distance vision (long sighted)?
Are these required for near vision (short sighted)?
Has your child ever used coloured overlays/precision tinted lenses?
If 'yes' please tell us who recommended them, why they were recommended and if they helped (in what way)? Does your child still use them?
Has your child ever had hospital treatment for a problem with their eyes or vision? For example wearing a patch, having eye exercises prescribed etc)
In some cases, difficulties with reading are caused by visual difficulties that are not related to learning. Visual difficulties MUST be investigated before a dyslexia assessment.

Please answer simple YES/NO to the questions below. Please note the emphasis on the word often in questions 1-9, which is deliberately intended to identify when a symptom occurs frequently. Please answer NO if reported symptoms would be considered infrequent (e.g. rarely, occasionally, sometimes, less than 2-3 times per month).

often = persistent, occurring several times a week, though not necessarily every day

You may need your child to help you answer these questions.

Rows	Yes	No
Does your child often get headaches when they read or study?
Do their eyes feel sore, gritty or watery?
Does reading from white paper or from a bright screen often feel uncomfortable?
Does print often appear blurred, or go in and out of focus when they are reading?
Does the print in a book or on screen often appear double when they are reading?
Do words often seem to move or merge together when they are reading?
Do objects in the distance often appear more blurred after your child has been reading?
Do they often have to screw up their eyes to see more clearly when they are reading?
Do they often move your eyes around or blink to make things clearer or more comfortable when you are reading?
Do they experience any other problems with their vision that interfere with their ability to read and study

If 'Yes' to any of the above questions, please tell us a bit more about what your child experiences
Do you have any concerns about your child’s hearing?
If yes, please confirm you will have this investigated before the assessment
Any other information you would like us to know
Our assessments take place either at school or in the child's home. Where would you like the assessment to take place? If you would like the assessment to take place in school it is your responsibility to check with the school that they can accommodate the assessment
Has your child previously had a dyslexia screening with SPACE in the last 12 months? If 'yes' please contact us as you may be entitled to a £15 discount on the full assessment cost
I understand that a dyslexia assessment can take between three to four hours to administer, and with appropriate breaks, I believe my child will be able to manage this. I also understand that my child needs to be at least 8 years old to be eligible for this assessment
If you have any questions or would like to discuss anything on this form, please email services@spaceherts.org.uk
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