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Dyslexia
Teachers
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Info
Name
*
Email
*
Mobile
*
Gender
*
Male
Female
Date of Birth
*
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--Year--
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1930
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1925
1924
Address
*
Nationality
*
Jordan
United Arab Emirates
Bahrain
Algeria
Saudi Arabia
Sudan
Somalia
Iraq
Kuwait
Morocco
Yemen
Tunisia
Comoros
Djibouti
Syria
Oman
Palestine
Qatar
Lebanon
Libya
Egypt
Mauritania
Spain
Australia
Afghanistan
Argentina
Albania
Brazil
Portugal
Sweden
China
Philippines
Germany
Mexico
Norway
Austria
India
United States of America
Japan
Greece
Indonesia
Uruguay
Uzbekistan
Ukraine
Iran
Ireland
Italy
Britain
Benin
South Africa
Russia
Singapore
Switzerland
Ghana
France
Canada
Korea
Nigeria
Pakistan
England
Highest qualification obtained
*
Student’s First Language
*
Current Mood
I lost the desire and energy to do the things I used to do before
No
Rarely
Sometimes
Often
I feel sad, upset and unhappy
No
Rarely
Sometimes
Often
I don't sleep easily
No
Rarely
Sometimes
Often
I sleep alot
No
Rarely
Sometimes
Often
I feel lethargic, lazy, and do not want to move
No
Rarely
Sometimes
Often
I lost my appetite
No
Rarely
Sometimes
Often
I eat a lot but I don't enjoy what I eat
No
Rarely
Sometimes
Often
I have a negative image regarding myself, and I don't like myself
No
Rarely
Sometimes
Often
I feel that I let my family and those close to me down
No
Rarely
Sometimes
Often
I find it hard to focus
No
Rarely
Sometimes
Often
I started to speak and move very slowly and it's quite noticeable now
No
Rarely
Sometimes
Often
I'm starting to feel anxious and unable to settle down
No
Rarely
Sometimes
Often
I feel that life is not worth living
No
Rarely
Sometimes
Often
Complete the following sentence
*
If life is a sea, then
But
therefore
What does failure mean to you? Can you provide a definition of failure according to your understanding?
*
Do you consider that you have failed in the past in certain things in your life?
*
Yes
No
Do you feel that you are failing now?
*
Yes
No
What is the main objective of the service request/session?
How did you hear about us? (You can choose multiple)
*
School referral
Assessment Centre referral
Intervention Centre referral
Referral from a friend
Social media adverts
Flyers
Online search
Other
Centre name
Other Referral
Additional information you would like to add
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