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Driving and Theory Support Questionnaire (SEND)

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Driving and Theory Support Questionnaire - Step 1 of 17

Information About You

What is your name? *

First

Last

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Information About You

What is your date of birth? *

For example, 31 03 1990

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Information About You

What is your address?

Type your POSTCODE and select the correct address from the dropdown menu. *

Add the HOUSE NUMBER or name in the box *

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Information About You

What is your email address?

No email address

I do not have an email address.

What is your phone number? *

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Your Driving Licence

Do you have a provisional driving licence?

Yes
No
I have applied for one, but it has not arrived yet.

Your Driving Licence number is the 16 digit number found on the front of your licence card, as shown in this photo.

What is your Driving Licence number?

No driving licence number

I do not have a driving licence number.

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Questions About Your Doctor

What is the name of your GP (Doctor)? *

What is the address of your GP? *

What is your GP's phone number?

Have you been given any medicines by your doctor? *

Yes
No

If 'Yes', please list all of the medicines you have been given by your doctor.

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School and Exams History

Do you have any of the following support at School or College?

Extra time
A separate room or other adaptation
Writing or computer help
Someone to read aloud to you
Someone to write for you

Tick all that apply.

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Preparation for the Theory Test

What do you see as a barrier to being able to pass the theory test?

Memory
Reading and writing (understanding the questions)
Concentration or attention
Managing my time
Other (use the box below to add details)

Tick all that apply.

Barrier to passing the theory test, details

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Preparation for the Theory Test

Are you worried about any of the following?

How I will get to the Theory Test centre
Being in a new or different environment
Sitting down and concentrating for the test
Having sufficient time to complete the test
I am not particularly worried
Other (use the box below to add details)

Tick all that apply.

Worries about the Theory Test, details

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Preparation for the Theory Test

Do you have any of the following?

A 'smart phone', for example an iPhone
Internet
Computer
Theory Test revision book
Theory Test app - such as 'Theory Test Pro'

Tick all that apply.

When do you hope to take your Theory Test?

In the next 6 months
In 6 to 12 months
12 months or longer
I have already booked it
I have already passed it

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Medical Conditions

Have you ever been told you have any of the following conditions?

Dyslexia
ADHD
Autism
Dyspraxia
Dyscalculia
Anxiety
Other learning difficulty
None of these conditions

Tick all that apply.

Do you have any additional medical conditions?

Describe your physical ability (Neck, Arm and Leg movement).

Can you walk without help?

Yes
No

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Skills

How would you rate your reading skills?

Poor
Okay
Good
Great

How would you rate your writing skills?

Poor
Okay
Good
Great

How is your concentration when focusing on a task or test?

Poor
Okay
Good
Great

How well do you feel you cope during tests or exams?

Scared
Nervous
Comfortable
Very confident

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Driving Information

How do you feel about learning to drive?

Scared
Nervous
Comfortable
Excited

Why is driving important to you?

I want to be independent
I need to drive to get to work
To be able to visit my friends
To get to the shops
To be able to go on holiday and days out
Volunteering
Other (use the box below to add details)

Driving importance, details

Which type of car would you like to drive?

Manual - where a 'clutch' is used to change gears.
Automatic - changing gears is automatic.
Adapted car - for example, fitted with an assisted steering device.
Not sure

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Learning to Drive

Have you taken any driving tuition?

Yes
No

If yes, approximately how many hours have you taken?

What difficulties are you experiencing with practical driving?

If none, continue to the next question.

Have you taken your Theory Test before or have one booked?

Yes
No

How many times have you attempted the Theory Test?

Did you book this test yourself?

Yes, on my own
Yes, with help
No, someone else booked it.

If someone booked it for you, what is their name?

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Help and Support

If you have taken the theory test, did you have any of the following support?

I was given a quiet room
An Oral Language Modifier (OLM) helped me
I was allowed extra time
None of the above
Something else not listed here

List any additional support you receive that has not been previously mentioned within this form

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Help and Support

Please tell us about anything that stops you from doing things on your own and any help or equipment you need.

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Who filled in this form?

Your National Insurance number can be found on the front of your National Insurance card. See below for an example.

What is your National Insurance number (NI)?

We need this in order to undertake a Driving Licence check

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Use the Submit button to complete the Driving and Theory Support Questionnaire.

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Welwyn Garden City
Hertfordshire
AL8 7SR

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