Chaffey College Disability Programs & Services LD Referral Form

Transcription

1 Chaffey College Disability Programs & Services LD Referral Form Date: Name: Student ID#: Address: City: Zip: Phone: Alternate #: DOB: Referring DPS Counselor: Who referred you for LD testing? 1. Are you currently a DPS student? Yes 2. Are you currently enrolled in classes at Chaffey? Yes Number of units you are currently taking? 3. Do you take medication on a regular basis? Yes 4. Does anyone in your family have an identified learning problem? Yes 5. Do you now or have you had a Vision problems (not correctable with glasses/contacts) Yes Problem with hearing. Yes Head injury (i.e., external or internal trauma)... Yes Seizure disorder (What type of seizures?) Yes History of mental health problems Yes History of substance abuse (what, how long, x sober) Yes For each yes response, describe fully 6. Diagnosis of Developmentally Delayed or Disabled? Yes 7. What is your language of Origin? 8. Have you ever been in Special Education/RSP/or LD tested classes? Yes When? Where? 9. Subject(s) you are experiencing difficulties with? Attention span Memory Difficulty Following Directions Easily confuse letters, numeral, or sounds Poor reading and/or writing abilities Difficulty with putting words/thoughts in the correct order Eye-hand Coordination problems; poorly coordinated Disorganization and other Sensory difficulties 10. When did the Learning difficulties start? Was there a significant event going on in your life during this time? Office use only: Received by LD Specialist: / / Initials Referred for LD Testing: Yes / No Outcome of Referral: Tested: No - Criteria Not Met Obtain Med/Psych Documentation Other: Yes - LD Eligible DDL Not LD Eligible Other: 4/15 SB

2 Chaffey College Disability Programs & Services Application for Services Form Student s Name: ID #: Date of Birth: Address: City: State: Zip: Phone #: Cell Phone #: Chaffey College provides educational services and access for eligible students with documented disabilities who intend to pursue coursework at the college. A variety of programs and services are available which afford eligible students the opportunity to participate fully in all aspects of college programs and activities through appropriate and reasonable accommodations. Completion of this form constitutes an agreement to apply for Disability Programs and Services. How did you find out about the program? Website Friend College Counseling College Instructor High School staff Other DPS has provided me with voter information Yes No Are you a veteran? Yes No I understand that participation in the Disability Programs and Services program is strictly voluntary. Student Signature: Date: Signature of parent or guardian: (Parent signature required if student is under 18 years of age) _ Office use only: Received by DPS Staff: / / Initials

3 Chaffey College Student: Learning Disabilities Testing Procedure and Questionnaire Chaffey College Disability Programs & Services (DPS) If you are experiencing difficulties in meeting the academic demands of the regular vocational and/or academic classes at Chaffey College, you may request a learning disabilities assessment to determine the sources of your problems. You may be self-referred or referred by someone else within or outside of Chaffey College. Please take the time to complete the following questionnaire. It is important to answer each question in detail. Once the form is completed, submit to the front desk staff in DPS at Campus Center East. The Learning Disabilities Specialist will collect the questionnaire and review it. Providing this information is strictly voluntary. The information will be kept confidential and your answers will be used to help the Learning Disabilities Specialist determine an appropriate course of action. Learning Disabilities Testing Requirements and Procedures: It is important to note that you have to be a current Chaffey College student. In addition, you must be enrolled in at least one regular academic or vocational class (3 units or more) at Chaffey College. Testing will be suspended if: 1) You drop out of class/classes and are no longer enrolled as a Chaffey College student 2) You miss your first intake/testing appointment by not attending the appointment, being over 15 minutes late, or calling on the day of the appointment (medical verification needed to be excused), then you will be moved to the bottom of the waiting list. 3) You miss two appointments/counted as absent if over 15 minutes late for appointment OR if you call the day of the appointment/medical verification needed for an absence to be excused 4) You may challenge the suspension of testing by meeting the Learning Disabilities Specialist in person to discuss the situation. Learning Disabilities Testing Steps: Step 1: You need to complete and submit the following questionnaire with a LD referral form. Step 2: A phone call will be made once your questionnaire has been reviewed to determine the next course of action. Step 3: An assessment screening may or may not be scheduled. If an assessment screening is scheduled and completed, the results will help determine if you will be placed on the testing waitlist OR it will be determined that you will not go through a learning disabilities assessment. It is up to the discretion of the Learning Disabilities Specialist to skip screening to either move to a learning disabilities assessment OR discontinue the testing process. Step 4: If selected for testing, you will need to complete a Learning Disabilities Program Intake Screening packet in DPS. Once completed, you will be scheduled for a series of testing appointments. Step 5: Once testing is completed, you will be invited to a final results appointment.

4 Learning Disabilities Testing Questionnaire Chaffey College Disability Programs & Services (DPS) Name: Chaffey ID Number: Date: Contact Information: ( ) - Who referred you? Address: Please answer the following questions: Medical History: Have you had a head injury? Have you ever been diagnosed with a medical condition? If so, please state the condition. Are you on medication? Do you have a history of seizures? Any vision problems? Any hearing problems?

5 Educational History: Have you ever repeated a grade during K-12? Have you ever received special education services, such as an Individualized Education Plan (IEP) or Speech- Therapy? How long have experienced learning difficulties? What is your goal at Chaffey College? Please circle the letter Y for YES or the letter N for NO: Reading: Slow reader? Y or N Skip words, re-read lines when reading aloud? Y or N Substitute, delete, add or transpose letters and syllables? Y or N Read words backwards? Example: was for saw, net for ten. Y or N Difficulty sounding words? Y or N Struggle with reading comprehension? Y or N Expressive Language/Writing: Problems with spelling and grammar? Y or N Difficulty expressing ideas/thoughts coherently on paper? Y or N

6 Do you spell based on what you hear (phonetically) as opposed to proper spelling? Y or N Organized writer? Y or N Reverse letters OFTEN when spelling? Example: Friday becomes Firday. Y or N Poor handwriting? Y or N Math: Difficulty remembering math sequences? Y or N Difficulty with addition/subtraction, multiplication/division)? Y or N Difficulty copying numbers and symbols? Y or N Read numbers backwards? Example: 18 for 81, 21 for 12? Y or N Difficulty remembering math concepts? Y or N Attention: Difficulty concentrating/focusing? Y or N Easily distracted? Y or N Impatient? Y or N Executive Functioning: Poor organizational skills? Y or N Poor use of time? Y or N Difficulty prioritizing, grouping or categorizing? Y or N Difficulty assembling puzzles? Y or N Difficulty reading maps, graphs, charts? Y or N Memory: Difficulty remembering relevant information? Y or N Difficulty holding information rapidly? Y or N

7 Difficulty retrieving previously stored knowledge? Y or N Need to repeat information to learn effectively? Y or N Problems remembering visually presented information? Y or N Problems remembering auditory information? Y or N Are you forgetful? Y or N Other: Difficulty taking notes? Y or N Difficulty completing exams within class time? Y or N Use the space below to report other learning difficulties. Please be specific: I have read and understand the Learning Disabilities testing procedures. Signature: Date: