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Certified Irlen® Screener & Educational Consultant

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The Irlen® Self Tests

These simple Yes/No tests, which you can complete at home in your own time are intended to provide an indication about whether you may need to consider professional screening for Irlen® Syndrome. I ask for your contact details so that I can contact you to discuss the screening results with you, in confidence.

You are under no obligation to undertake a full screening assessment; nor will your details be used to promote my services in the future. Most importantly your contact details will not be passed onto any third parties. If, as a result of completing this form and discussing the results you decide to go no further with the process then the information and the form will be destroyed.

Please complete the form below. Once I have reviewed your answers, I will contact you to discuss the screening results with you.

NOTE: YOUR EXPERIENCES CAN BE IN THE PAST, WHEN IN SCHOOL, AS WELL AS THE PRESENT.

Please put your child’s name here if you are completing on behalf of your child.
Please tick the options that you answer ‘yes’ to
Please tick the options that you answer ‘yes’ to
Please tick the options that you answer ‘yes’ to
Please tick the options that you answer ‘yes’ to
Please tick the options that you answer ‘yes’ to
Please tick the options that you answer ‘yes’ to
Please tick the options that you answer ‘yes’ to
Please tick the options that you answer ‘yes’ to
Please tick the options that you answer ‘yes’ to
Please tick the options that you answer ‘yes’ to
Please tick the options that you answer ‘yes’ to
Please tick the options that you answer ‘yes’ to
Please tick the options that you answer ‘yes’ to
Please tick the options that you answer ‘yes’ to

Do any of the following bother your eyes, head, and stomach; make you dizzy, tired, nervous, anxious or irritable?

Please provide a valid email address so I can contact you with your results.

self test for Irlen Sydnrome

Content Source: Irlen.com