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SMC|Student Services|Disability Resources|Learning Disabilities INTAKE SCREENING

Learning Disabilities INTAKE SCREENING

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Date:___________________

Name:______________________            Birth date:_______________       Student ID#:____________

Address:_________________________________________________    Phone #__________________

Email____________________________________________________

Gender: __________                             Ethnicity:____________________________________________ 

  Who referred you to our program? ______________________________________________________

  Reason for referral:___________________________________________________________________ 

  Academic goals:______________________________________________________________

  Last semester’s classes:                        Grade                           Instructor
________________________                  _____                           ___________________

________________________                  _____                           ___________________

________________________                  _____                           ___________________

________________________                  _____                           ___________________

Current classes:                                                                        Instructor
________________________                                                      ___________________

________________________                                                      ___________________

________________________                                                      ___________________

________________________                                                      ___________________

Describe any difficulties you are having in these classes:

 

In what classes have you done well?

Have you ever been tested for Special Education?___________________________________________

What grade?________________________________________________________________________

Placement: (Indicate grade level):   Resource_______  Special day class________    Remedial________

In elementary school do you remember having trouble with:  (please explain if possible)

             Learning to read?

             Spelling?

             Math?

Do you have any physical disability that inhibits academic performance? (Please explain)

__________________________________________________________________________________

Is there a history of learning disabilities in your family?_______________________________________

Have you ever been treated for psychological or emotional problems?___________________________

__________________________________________________________________________________

  Is English your 1st language?  _________                    If not, what is? _________________________

             When did you first learn to speak English?__________________________________________
 
             How would you rate your English skills at this time?___________________________________

              Did you have learning difficulties in your native language?  (explain)______________________

           _____________________________________________________________________________
 
            _____________________________________________________________________________

  Are you a High School Graduate?  _________

  High School:______________________________________________  Year graduated________

  Rate the level of difficulty for each of the following  subjects:

           (5 - very difficult,        4 - difficult,        3 - moderate,        2 - easy,        1 - very easy)

 
            _____English                           _____Math

            _____Foreign Language          _____Sciences

  Using the same scale, how would you rate your  level of difficulty  in the following study skills:

           _____Textbook reading                              _____Note-taking

            _____Memory                                            _____Organization

            _____Essay writing                                    _____Spelling

            _____Math                                                 _____Test-taking 

Please explain any rating of 4 or 5:

How do you compensate for the difficulties you experience? (in your classes, either with
subject matter or study skills)

Have you repeated any classes?  Which ones?


For us to better understand you, please describe the problems you have been having at
SMC and in your past learning .  Please use this opportunity to tell us anything we should know
about you in order to make recommendations.  (PLEASE write 2 - 3 paragraphs. We NEED
a sample of your writing! Thanks.)

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             (Stop here - the following  is for our records)


                                                                                       RECOMMENDATIONS

LEARNING DISABILITIES ASSESSMENT:       

COURSEWORK:

STUDY STRATEGIES:

TUTORIAL:

COMMENTS:

 

                                                                      LD Specialist________________________________