Adult Learning Disability Evaluation Intake Form

Full Name

First NameMiddle NameLast Name

Date of Birth

Date

Preferred Contact Method

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

City and State

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Best Time to Contact

Hour Minutes

AM/PM Option

Primary reason for seeking a learning disability evaluation

Specific academic or work difficulties

When were these concerns first noticed?

Recent changes that prompted this request

Highest Level of Education Completed

Current School, Training Program, Employer, or Role

School Experience and Academic History

Please describe any important details about your learning history

Please describe any school, training, or work history details you would like the evaluator to know

Reading comprehension difficulty

Written expression difficulty

Spelling difficulty

Math difficulty

Attention difficulty

Memory difficulty

Time management difficulty

Organization difficulty

Following instructions difficulty

Test-taking difficulty

Known childhood learning concerns

Early speech or language delays

Hearing or vision concerns that may affect learning

Diagnosed conditions that may affect learning

Current medications

Family history of learning difficulties

Have you had any prior evaluations?

Approximate date of most recent evaluation

Brief results or findings from prior evaluations

Which supports or services have you used?

Details about prior assessments, supports, and helpful or unhelpful services

Preferred language for the evaluation

Accessibility needs

Preferred communication method

Interpreter or assistive technology needed

Preferred appointment availability

Adult Learning Disability Evaluation Intake Form

Intake & Contact Information

Reason for Evaluation

Learning, Education, and Work History

Current Functional Challenges

Developmental, Medical, and Family Background

Prior Assessments and Support Services

Communication, Accessibility, and Scheduling Needs