Learning Disabilities Screening Questionaire

Disabled Students Programs & Services

Learning Disabilities Screening Questions
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What is a Learning Disability?

Learning disabilities are learning differences which may interfere with the ability to understand, remember, and/or use information. The effects are quite individual, but it is generally accepted that these difficulties create a gap between a person’s true capacity and his or her day-to-day performance and productivity.

These learning differences may include difficulties with:
- Attention or concentration
- Memory
- Visual and/or auditory processing
- Spatial orientation
- Language
- Reasoning
- Sequencing
If appropriate, we can provide you with a learning disability assessment, but we are not creating a diagnosis.

We are not assessing any of the following conditions:
- ADHD
- Anxiety
- Autism
- Mental Health Disabilities
- Any condition that requires an actual diagnosis...

Please answer the following questions
Do you have an disability diagnosis?*

I have no disability diagnosisI have a disability diagnosis but no documentationI have a disability diagnosis and hard copies of my documentationI have a disability diagnosis and electronic copies of my documentation
What is your diagnosis?*
Please upload the electronic copy of your disability paperwork below and then proceed to the Learning Disability Screening.*

IEP, Assessment reports, Placement tests, Transcripts
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Please bring all copies of your disability documentation to the DSPS office.

STUDENTS PLEASE NOTE
- LD Screenings are reviewed regularly.
- Be certain to provide us with a good contact number and email.
- We cannot Text & your Voicemail must be set up.
- Please make sure to answer every question in detail.
- Incomplete forms will cause a delay in services
How did you hear about the DSPS Program/Services?(Please provide full name of person that referred you.)
What are your goals Short-term & Long-term for school or career?
What are you hoping to get from our meeting?
Have you ever been diagnosed with any type of disability? If so, please provide current documentation. (IEP, Assessment reports, Placement tests, Transcripts?)*
Please explain the learning difficulties you are having?
When did you first start having them?
What specific areas do you struggle with (What subjects have you struggled with?)
What steps have you taken so far to improve i.e., tutoring, repeated classes?
What do you think would be helpful for your learning? Specific accommodations requested?
Does anyone in your immediate family have learning problems (Diagnosed or Undiagnosed?)
Do you have a history of medical or Psychological problems?

YesNo
Are you or is there a history of taking medications? If yes, which ones?
How often do you drink alcohol? Smoke marijuana? Other drugs?
Have you ever had a serious head Injury, brain injury, or concussions? If so, what happened?
Are you working? If yes, include your work history.
Anything else you would like to share?
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Disabled Students Programs & Services