Nonverbal Learning Disability Checklist Form
Use this form to record observations, strengths, challenges, and support needs related to nonverbal learning disability traits.
Respondent Information
Full Name
*
First Name
Last Name
Role or Relationship to the Person Being Assessed
*
Self
Parent/Guardian
Teacher
Therapist
Other
Age or Grade Level of the Person Being Assessed
*
Observation Context
Primary setting where observations apply
*
Home
School
Work
Clinical
Mixed settings
Other
Frequency/duration of concerns
*
Please Select
Recently noticed
Occasional
Frequent
Longstanding
Nonverbal Learning Disability Checklist
Observed strengths and challenges
*
Strong verbal skills
Difficulty reading facial expressions or body language
Trouble understanding gestures
Missed social cues
Uneven visual-spatial skills
Difficulty with directions or maps
Clumsiness or coordination issues
Strong memory for facts
Anxiety in unfamiliar settings
How often or how strongly do these concerns appear?
*
Never
1
2
3
4
Very often
5
1 is Never, 5 is Very often
Notes, examples, or observations
Support Needs and Follow-Up
Current supports already in place
Classroom accommodations
Coaching or mentoring
Tutoring or academic support
Family strategies at home
Therapy or counseling support
None
Other
Desired follow-up or next step
*
General guidance
School support ideas
Coping strategies
Referral discussion
Other
Submit Checklist
Should be Empty: