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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
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Current classes:
Instructor
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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)
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Is there a history of learning disabilities in your family?_______________________________________
Have you ever been treated for psychological or emotional problems?___________________________
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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)______________________
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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________________________________