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:_________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
