CHILD CONFIDENTIAL QUESTIONNAIRE  

PERSONAL DETAILS  

DEVELOPMENT HISTORY  

Yes
No
Yes
No
Yes
No
Yes
No

SCHOOL HISTORY  

Current National Curriculum Levels (if appropriate) 
What are the particular difficulties exhibited in school?  
Slight
Moderate
Severe
Slight
Moderate
Severe
Slight
Moderate
Severe
Slight
Moderate
Severe
Slight
Moderate
Severe
Yes
No
Yes
No
Unavailable
Yes
No
Yes
No
Yes
No
Yes
No

BACKGROUND INFORMATION  

Yes
No
Yes
No
Yes
No

TERMS & CONDITIONS  

Signing and returning the Booking Form secures your date/place - Payment of invoice is due in advance by BACS in advance. A separate invoice with banking details and will be sent to the email on the Booking Form. I am afraid I cannot accept personal cheques. 
For INSET sessions a copy of the presentation will emailed in advance with any handouts to be photocopied by the school ( preferably on non white paper). 
If there are over 50 attendees the trainer will need to be notified in advance. 
For assessments the report will be returned within 15 working days but will be retained if payment is not made. 
 

CANCELLATION CHARGES  

1. If you are unable to go ahead with the training/assessments, you must advise Positive Dyslexia as soon as possible, at least 48 hours in advance. 
2. Positive Dyslexia will endeavour to rearrange the date to a mutually convenient time. 

DATA PROTECTION ACT 2018 

The information you provide on this form will be used by Positive Dyslexia to process your booking request. From time to time we would also like to send you information about our other services. 
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