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Dyslexia & Neurodiversity Assessments N.I. (DNA-NI)
Intake form
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Name
*
Email address
*
What type of assessment are you interested in?
Please select at least one option.
Dyslexia Assessment
Dyscalculia Assessment
Workplace Assessment
Medico-Legal Report
What is your age?
What is your gender?
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Male
Female
Non-binary
Prefer not to say
What is your current occupation?
Do you have any previous assessment history?
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Yes
No
If yes, please provide details about previous assessments.
Have you been diagnosed with any learning difficulties?
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Yes
No
If yes, please specify the learning difficulties diagnosed.
What is your preferred method of contact?
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Phone
Email
In-person
Please describe any specific concerns or issues you would like to address during the assessment.
Additional questions or comments
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