Learning Difficulties Screening Form
Please complete this screening form to help us better understand learning needs and challenges. This is not a diagnostic tool.
Full Name
*
First Name
Last Name
Age
*
Relationship to the person being screened
*
Self
Parent/Guardian
Teacher/Educator
Other
Email Address
*
example@example.com
What learning challenges or concerns have you noticed?
*
Difficulty reading
Difficulty with writing or spelling
Trouble with math concepts
Short attention span
Difficulty following instructions
Other
How often do these challenges occur?
*
Rarely
Sometimes
Often
Almost always
Which learning style seems to work best?
Visual (seeing, reading, diagrams)
Auditory (listening, spoken instructions)
Kinesthetic (hands-on, movement)
Not sure
On a scale of 1 to 5, how much do these learning challenges affect daily activities?
*
Not at all
1
2
3
4
A great deal
5
1 is Not at all, 5 is A great deal
Has any support or intervention been tried previously?
No support tried
Tutoring
Classroom accommodations
Specialist referral
Other
Please share any additional observations or relevant information.
Submit
Should be Empty: