WOODLAND COMMUNITY COLLEGE
Department of Supportive Programs and Services (DSPS)
2300 East Gibson Road, Building 700, Room 764, Woodland, CA 95776
Phone: (530) 661-5797 Fax: (530) 661-5788 Email: wccdsps@yccd.edu
Intake Interview Questionnaire
_______________________________ __________________________ __________________________
Student Last Name First Student ID
_______________________________ __________________________
DOB (MM/DD/YY) Date
Are you a currently enrolled student? Yes No
At which campus do/will you take classes? Woodland Colusa Clear Lake
Do you plan to take online classes? Yes No
If enrolled, how many units are you taking? _______ What is your major? _______________________________
What classes are you taking?_________________________________________________________________________
________________________________________________________________________________________________
What are your goals for college? _____________________________________________________________________
________________________________________________________________________________________________
Have you previously attended other colleges/institutes, or served in the military? If so, please explain: ______________
________________________________________________________________________________________________
How many college units have you previously completed? _________________________________________________
Describe the problems/challenges you experience with learning: ____________________________________________
________________________________________________________________________________________________
Check specific areas of difficulty that you experience:
Reading Writing Math
word recognition spelling basic math
remembering what you read handwriting fractions
understanding the main idea organizing thoughts in writing algebra
having to re-read often grammar, punctuation, etc. other__________
Notes:___________________________________________________________________________________________
________________________________________________________________________________________________
Additional Health Information:
Do you have vision problems? Yes No Do you wear corrective lenses or contacts? Yes No
When was your last eye exam? ______________
Do you have hearing problems? Yes No Have you experienced a serious head injury? Yes No
Academic Year:____________
Summer
Fall
Spring
Have you ever been diagnosed for any of the following?
Learning Disabilities Yes No
If yes, please briefly explain (type, when, where): ________________________________________________
Attention Deficit Disorder (ADD/ADHD) Yes No
If yes, please briefly explain (at what age, grade level, etc.): ________________________________________
Physical Disability or Injury Yes No
If yes, please briefly explain (type, severity, when): ______________________________________________
Psychological Disability or Diagnosis Yes No
If yes, please briefly explain (type, severity, when): ______________________________________________
History of Substance Abuse Yes No Currently sober/clean? Yes No
Period of time sober/clean: ____ years ____ months
Notes:________________________________________________________________________________________
Are you currently in individual or group counseling? Yes No
Notes:________________________________________________________________________________________
Are you currently seeing a physician/psychiatrist? Yes No
Are you currently taking prescribed medication(s) for any of the above? Yes No
If yes, what are you taking, and how long have you been using the medication(s)? ___________________________
_____________________________________________________________________________________________
Do any side effects of the prescribed medication(s) affect your learning or major life activities?_________________
_____________________________________________________________________________________________
Have you ever attended Special Education or remedial classes in school? Yes No
If yes, please indicate: RSP or Tutorial Special Day Class (SDC) Other _______________________
Have you received speech therapy? Yes No If yes, at what age? _________________________
Have others in your family been diagnosed with learning problems or learning disabilities? Yes No
If yes, please briefly explain (whom, type, etc.): ______________________________________________________
Please describe any current other personal or family issues that are impacting your education at this time:
________________________________________________________________________________________________
________________________________________________________________________________________________
Additional Notes:_________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
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