Form A - Trainee Dyslexia Application Form

Might dyslexia be an issue for you?

In certain circumstances the PSU's Individual Support Team (IST) is able to fund a diagnostic assessment with an educational psychologist in order to assess whether dyslexia (or other specific learning difficulty) is contributing to any difficulties you may be experiencing.

However as a formal diagnostic assessment with an educational psychologist is costly, there is a preliminary screening process to review whether there are adequate grounds for suspecting that any difficulties you may be experiencing are due to dyslexia, or other specific learning difficulty.

We have tried to keep the preliminary screening process as straightforward as possible and would ask you to do the following:

Check your score from the British Dyslexia Association adult checklist
Complete the questions in Form A.
Ask your educational or clinical supervisor to complete Form B

Title *

First name *

Last name *

Email Address *

Work Address *

Post code *

Gender *

I self-identify as

Telephone Number *

GMC/GDC/NMC or other registration number *

Profession *

Other profession

Stage of training *

Other stage

Position/Grade *

Other position/grade

Job title *

Medical or dental specialty? *

Medical

Dental

Specialty *

Other specialty

Ethnicity *

Specify ethnicity if not above

LETB *

Other LETB

Do you consider yourself to have a disability? *

Yes

No

Prefer not to say

Trust *

Other trust

Place of Primary Qualification *

UK

IMG (International Medical Graduate)

What are your reasons for wondering whether your performance is affected by dyslexia? *

Have you completed the British Dyslexia Association online checklist? *

Yes

No

Date of Test

Day

Month

Year

Score *

Name of Supervisor *

If a full educational psychology assessment goes ahead I agree to share and discuss the findings and recommendations with my educational or clinical supervisor? I understand a copy of the full report will be provided to the Professional Support Unit. *

Yes

No

Confirmation *

By clicking here you will confirm that you have accepted the terms of our privacy statement.

What happens next?

A member of the Professional Support Unit will review Form A and Form B and decide whether to fund a full and formal assessment with an educational psychologist.

If they are able to fund the assessment, a referral to an educational psychologist will be made by the Professional Support Unit. You will be notified of this and the cost of the assessment will be met by the PSU.

If they are not able to fund the assessment you are still able to access the PSU services in order to discuss any educational or career difficulties that you may be experiencing.