Learning Disabilities Screening Questionaire

Disabled Students Programs & Services

Learning Disabilities Screening Questions
Student’s Name
Current GPA*
Student ID#*
Semesters @ Rio Hondo?*
Semesters @ Rio Hondo?*

Full-timePart-time
Primary Language
Major
Any other colleges attended?
Date

MonthDayYear
Phone Number*
(123) 456-7890
Email*
example@example.com
STUDENTS PLEASE NOTE

LD Screenings are reviewed periodically. Be certain to provide us with a good contact number and/or email (We cannot Text & Voicemail must be set up).

Otherwise you are responsible to follow up with us.

(Please make sure to answer every question in detail. Incomplete forms will not be processed.)
1. How did you hear about the DSPS Program/Services?(Please provide full name of person that referred you.)
2. What are your goals Short-term & Long-term for school or career?
3. What are you hoping to get from our meeting?
4. Have you ever been diagnosed with any type of disability? If so, please provide current documentation. (IEP, Assessment reports, Placement tests, Transcripts?)
5. Please explain the learning difficulties you are having?
A. When did you first start having them?
B. What specific areas do you struggle with (What subjects have you struggled with?)
6. What steps have you taken so far to improve i.e., tutoring, repeated classes?
7. What do you think would be helpful for your learning? Specific accommodations requested?
8. Does anyone in your immediate family have learning problems (Diagnosed or Undiagnosed?)
9. Do you have a history of medical or Psychological problems?

YesNo
10. Are you or is there a history of taking medications? If yes, which ones?
11. How often do you drink alcohol? Smoke marijuana? Other drugs?
12. Have you ever had a serious head Injury, brain injury, or concussions? If so, what happened?
13. Are you working? If yes, include your work history.
14. Anything else you would like to share?
Should be Empty:

Disabled Students Programs & Services