Parent Referral Form - Confidential

Parent(s)/Carer(s) Name

School Name

Parent Email

Parent Phone

I give consent for my child to receive a Literacy Skills assessment - Dyslexia Screener

I have read the Clinic information sheet and understand that this is not a diagnostic assessment

Student (full name)

Birthday

Day

Month

Year

Year Group

Please identify any issues with attendance/prolonged period(s) of absence(s) or punctuality

Please tick the relevant boxes to identify any EAL (English as an Additional Language) needs

My child is not an EAL learner - please do not tick any other boxes

My child is an EAL Learner

My child started speaking English before the age of 7

My child started speaking English after the age of 7

My child speaks fluent English

My child is not yet speaking fluent English

Please identify any relevant diagnosis or referrals to other agencies

Does your child wear glasses?

Yes

Other than wearing glasses are there any other reported difficulties with vision?

Yes

Are there any reported difficulties with hearing?

Yes

Current attainment in reading and writing - please get this information from the school SENCO

Did your child pass the Year 1 Phonics Screening check? Please get this information from the school SENCO

Yes

Reason for referral - please discuss with the school SENCO as well as detailing any parental concerns

Please outline details of any school-based interventions or resources used to address the literacy needs of your child - please get this information from the school SENCO

Please provide any other information that may be useful to know for this assessment eg. allergies, medical/emotional /behavioural needs. is the student a looked after child?

Clinic Information Sheet

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