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Dyslexia Questionaire
Complex Care Counselling
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Dyslexia Questionaire
Dyslexia Questionnaire
This form is based on select the answer, no writing required
Who is completing this form?
If person plus another, please select each one who is completing the form
Please tell us who is completing the form?
Person who wants counselling
Carer
Mother/Father
Family memeber
Social services
Other
Other
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Person who wants counselling
Name?
*
PostCode?
*
Date of birth
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Text
GP Details
Surgery Name
Postcode
Dr Name (if Known)
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My Dyslexia
Select 1 or more
Working Memory
English (written)
Maths
When were you diognosed
Pre-Teen
Teen
Adult
Never Tested
Other
Other
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Dyslexia Effects
Multi select available
None
Reading
Writing
Academic Performance
Time Management
Self-esteem and Confidence
Social Interaction
Career Opportunities
Emotional Well-being:
Other
Other
Lack of understanding (people)
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Social Situations
Person with Down Syndrome reactions
Feel anxious in public?
No
Yes
Sometimes
Lack support close friends?
No
Yes
Sometimes
Worry about people’s reactions?
No
Yes
Sometimes
Feel ignored by people?
No
Yes
Sometimes
Family Attachments
Not a problem
Reject
Overidialise
Switch Swiftly
Personal relationships?
Reject them
Overidialise
Swiftly interchange
People over sympathising
No
Yes
Sometimes
Isolation? (when stressed)
N/A
Often self isolates (Short period of time)
Often self isolates (extended period)
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Home?
Relationship?
Single
Divorced
Live-In-Partner
Married
Children?
Yes
No
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Employment?
Employed?
Yes
No
Status
Full-Time
Part-Time
Medically or Physically Able to Work?
Yes
No
Other
Other
Retired?
Yes
No
Student?
Yes
No
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Aspirations?
What is the aim of counselling?
Multi-select
Facilitating behaviour change
Enhancing coping skills
Facilitating your potential
Development of self-worth
Improving relationships
Reduce anger
Reduce negative feeling and thoughts
Explore broad set of issues
Reduce or remove addictions
Establish and maintain relationships
Remove or reduce negative cycles
Other
Other
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Next
Help With? (excluding Dyslexia)
What should we concentrate on to start?
Multi-Select
Addictions
Anger
Anxiety
Body Dysmorphia
Confidence
Chronic Fatigue Syndrome
Chronic Pain
Depression
Dissociative Disorders
Health Anxiety
Fibromyalgia
General OCD
Relationship OCD
Continued
Psychosis
Panic Disorder
Personality Disorder
Phobias
PTSD
Social Anxiety
Stress
Suicidal Thought
Self-Harm Thoughts
Other
Other
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Do You Require Mobility Assistance
Mobility Device?
*
Not Needed
Crutches
Supporting frame
Tilt-in-space
Manuel wheelchair
Standing wheelchair
Motorised wheelchair
Standing frame
Other
Other
Assistive Technology?
*
Not Needed
Electronic communication board
Low-tech communication board
Speech-generating device
Eye-tracking device
Typing and writing devices
Hearing Aids
Cochlear Implant
Other
Other
Multi-select
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Health
Any, Medication?
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
Other
Any, medical conditions
None
Alzheimers
Arthritis
Asthma
Blood Pressure
Cancer
Infectious Disease
Lung Conditions
Diabetes
Heart Issues
Stroke
Other
Other
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Any, Additional Disabilities
Do you have any additional disabilities?
Autism
Epilepsy
Hearing Loss
Medical Illness
Sight Loss
Other
Other
Hearing Loss
Mild
Moderate
Severe
Deaf/BSL User
Other
Other
Sight Loss
Mild
Moderate
Severe
Blind
Other
Other
Epilepsy Type?
Absence
Clonic
Focal
Generalised
Tonic-Clonic
Other
Other
Absence
Absence seizures are more common in children than adults and can happen very frequently. During an absence a person becomes unconscious for a short time. They may look blank and stare, or their eyelids might flutter. They will not respond to what is happening around them. If they are walking they may carry on walking but will not be aware of what they are doing.
Clonic
Clonic seizures involve repeated rhythmical jerking movements of one side or part of the body or both sides (the whole body) depending on where the seizure starts. Seizures can start in one part of the brain (called focal motor) or affect both sides of the brain (called generalised clonic).
Focal
As the seizure progresses, a person can experience motor and non-motor symptoms. Some motor symptoms of focal seizures include: muscle twitching jerking spasms repeated movements, like clapping or chewing Non-motor symptoms do not affect how someone moves. However, they may cause confusion or changes in emotions. Some non-motor symptoms of focal seizures include: waves of hot or cold goosebumps lack of movement changes in emotions or thoughts
Generalised
Generalised onset seizures affect both sides of the brain at once and happen without warning. The person will be unconscious (except in myoclonic seizures), even if just for a few seconds and afterwards will not remember what happened during the seizure. Unknown onset seizures are sometimes used to describe a seizure if doctors are not sure where in the brain the seizure starts. This may happen if the person was asleep, alone or the seizure was not witnessed. If there is not enough information about a person’s seizure, or if it is unusual, doctors may call it an unclassified seizure.
Tonic Clonic
These are the seizures that most people think of as epilepsy. The person becomes unconscious their body goes stiff and if they are standing up they usually fall backwards. They jerk and shake as their muscles relax and tighten rhythmically.
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NHS Past Counselling?
Any, Past NHS Counselling?
*
Yes
No
Normally CBT (General Counselling)
Approx when?
Approx how many sessions
Any other NHS sessions ?
No
Yes
General Counselling (CBT)
Approx, how many years ago?
Approx, how many sessions?
Any other NHS sessions?
No
Yes
Normally CBT.
Details on how many and year approx
Any, Specialist Counselling
Add as much information as possible.
Experience of NHS Counselling
Good
Did not understand my disability
Poor
Other
Other
Any, Specialist Consultations?
Add as much information as possible.
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Any other counselling?
What other counselling
No
Self-paid
Employer provided
School or university
Insurance
Profesional organisation
Other
Other
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Select, Sign or Print who has Completed this Form
If carer & person who wants counselling please both sign or print.
Confirmation of person who would like counselling
I confirm the information in this form is true to the best of my knowledge. I understand the information within this document will not be shared with any organisation or person without my written consent.
Signature
Confirmation of carer or person completing this form on behalf of the person who would like counselling
I confirm the information in this form is true to the best of my knowledge. I understand the information within this document will not be shared with any organisation or person without my written consent. I have the authority to complete this form by the person I am supporting.
Signature
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If Carer or Person Responsible
Name
Postcode
Phone
Email
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Submit