Allan Hancock College Learning Assistance Program Intake Screening

Student Name ID# College Date Month/Day/Year Term/Year Allan Hancock College Learning Assistance Program Intake Screening LAP Staff Only Type Caseload

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1. Have you been diagnosed with a learning disability or do you have a learning problem that is NOT associated with a physical or psychological disability? Yes No If yes, please fill out the ENTIRE Intake Screening packet completely. If possible, attach any copies of Individual Education Plans (IEP s) or assessment data to the application. 2. Have you been diagnosed with the following: Depression, Anxiety, Post Traumatic Stress Disorder, ADD/ADHD, or any other psychological disabilities? Yes No If yes, please fill out the ENTIRE Intake Screening packet completely. If possible, verification of disability should be attached to the application. 3. Do you have a physical disability or serious health limitation (examples: legal blindness, paraplegia, fibromyalgia, diabetes, arthritis, chronic pain, deafness )? Yes No If yes, please fill out the ENTIRE Intake Screening packet completely. If possible, verification of disability should be attached to the application. 2

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INTAKE INTERVIEW Learning Assistance Program Students: Allan Hancock College is required by law to gather and maintain some student information. This information is the race, sex, age, and disability status of students requesting services through the Learning Assistance Program. The law also requires that conditions of participation provide equal opportunity for all students. Providing this information is strictly voluntary for you. However, the college is required to complete each item since this form is the only means by which the college has for this information. For this reason, we ask your assistance in completing the form. DESCRIPTIVE INFORMATION Name (Print) Date Address Home Phone City Zip E-mail Address Cell Phone Work Phone Can you be contacted at work? Yes No Sex Age Date of Birth Place of Birth List name of person to notify in case of emergency: Name Relationship Phone 1. How do you describe yourself and your mother/guardian? (Please check one for each category). Alaskan Native...... American Indian...... Asian Cambodian...... Chinese...... Filipino...... Japanese...... Korean...... Laotian...... Pacific Islander...... Vietnamese...... Other Asian...... Self Mother/ Self Mother/ Guardian Guardian Black, non-hispanic...... Hispanic Central American...... Mexican...... South American...... Other Hispanic...... Middle Eastern...... White/Non-Hispanic...... Other Non-White...... Decline to state...... Unknown...... 4

BACKGROUND INFORMATION 2. Describe your strengths: School Work Related Personal Life 3. What are your short-term academic goals? 4. What are your long-term academic goals? 5. What are your long-term vocational goals? 6. Do you plan to transfer to a 4-year university? Yes No 7. What is/are your disabilities? 8. Are or were you a client of the Department of Rehabilitation? Yes No * If yes, please identify: a. What is your disability according to Dept. of Rehab.? b. Counselor s Name Phone c. What is your rehabilitation plan? 9. Are or were you receiving services from any of the following? (Check all that apply.) DSP&S EOPS Tutorial Financial Aid CalWorks Other Services 5

WORK HISTORY 10. Are you currently employed? Yes No * If yes, please describe current employment: a. Where? b. Job Duties? c. Number of hours per week? d. What is your weekly work schedule? e. How long have you had this job? Years Months Weeks 11. Describe any previous jobs, length of employment and job duties. HEALTH INFORMATION 12. Do you have vision problems? Yes No * If yes, describe: 13. Do you wear glasses or contact lenses? Yes No 14. Have you had an eye exam within the last two years? Yes No * If not, when? 15. Do you have problems with hearing? Yes No * If yes, describe: 16. Did you have frequent ear infections or tubes in your ears? Yes No 17. Do you wear a hearing aid? Yes No 18. Have you had a hearing exam within the last five years? Yes No * If not, when? 6

19. Have you ever had difficulties with any of the following? a. attention Yes No b. concentration Yes No c. hyperactivity Yes No * If yes, describe any difficulties with the following: a. study time b. classroom c. work d. social activities 20. Have you ever been evaluated for a psychological disability (i.e. depression, anxiety, bi-polar )? Yes No * If yes, when and by whom: What were the results? 21. Have you ever been evaluated for Attention Deficit (Hyperactivity) Disorder (ADD/ADHD)? Yes No * If yes, when and by whom: What were the results? 22. Are you on any medication at the present time? Yes No * If yes, please identify Name of Medication For What Condition Describe any Side Effects 7

23. Have you ever been on a long-term program of medication? Yes No * If yes, describe what kinds of medications and for how long did you take them 24. Have you ever had a head injury? Yes No * If yes, at what age? Were you hospitalized? Yes No * Cause of injury * Problems after injury 25. Have you ever been unconscious due to illness or injury? Yes No * If yes, for how long? Please explain * Problems after illness or injury 26. Have you ever had seizures? Yes No * If yes, specify when and describe 27. Have you ever had a neurological exam? (e.g. CAT scan, MRI)? Yes No * If yes, please answer the following questions: a. At what age? b. For what reason? 28. Have you ever had any serious injuries Yes No * If yes, specify when and please describe the impact on your education 29. Have you ever had any serious illness Yes No * If yes, specify when and please describe the impact on your education 8

30. Have you ever been hospitalized for emotional problems? Yes No * If yes, specify when and for how long Any impact on education 31. Have you participated in individual or group counseling? Yes No * If yes, explain 32. Do you have a history of substance abuse? Yes No * If yes, explain EDUCATIONAL INFORMATION If you have experienced problems with learning, please complete questions 33-39. If you have not had problems with learning, go to question 40. 33. As far as you can recall, when did you first start having problems in school? Grade Not applicable (Go to 40) 34. Why do you think you have had problems in school? (Check all that apply). Specific learning disability Tasks too difficult Bad luck Home environment Lack of interest in school Limited ability Emotional problems Lack of opportunity Poor attendance Economic disadvantage Other (specify) 35. Did you attend more than two elementary school (K-6) Yes No * If yes, explain: 36. Did you attend more than three schools in grades 7-12? Yes No * If yes, explain: 37. Were you retained in school, i.e. held back to repeat a grade(s)? Yes No * If yes, what grade(s) and why? 9

38. Were you ever tested for eligibility in special education prior to enrollment in college? Yes * If yes, when and why? 39. Have you ever been in special education, remedial, or gifted classes? Yes No *If yes, what type of classes? (Check all that apply.) Special Day Class Resource Program Remedial Class No Speech & Language serv. Gifted Other * If you were in special education or remedial classes, in what high school classes were you mainstreamed? 40. List all of your current classes. Describe any difficulties you are experiencing in each. How much time do you spend each week (including Saturday and Sunday) preparing for each of these classes? Weekly Class Describe Difficulties Study Time 41. Did you drop out of school between kindergarten and 12th grade? Yes No * If yes, please answer the following questions: a. what grade(s) b. for what reasons 42. Are you a high school graduate? Yes No * If yes, list name and location of high school * If no, did you complete a GED? Yes No * If yes, when? 10

43. Have you attended any other post college, university or technical school? Yes No * If yes, where? CULTURAL/LINGUISTIC HISTORY 44. Was English your first language? Yes No * If yes, skip Questions 45-50 and turn to page 9. * If no, please complete the remaining items 45. Which language(s) do you speak at home? English English and some other languages (specify) Other languages only (specify) 46. Describe any learning difficulties you had in your first language. 47. At what age did you begin to learn English? 48. Describe any learning difficulties you had in learning English. 49. In what grade did you first enter the United States school system? 50. Have you taken English as a Second Language (ESL) or bilingual classes? Yes No * If yes, describe how well you did in these classes 11

California Community Colleges Learning Disabilities Services CONSENT FORM The Chancellor s Office of the California Community Colleges is committed to protecting the rights of persons who are assessed for learning disabilities (LD) eligibility. The information below is provided so that you can decide whether to participate in the LD eligibility assessment. You are being asked to complete several assessment instruments that will help in determining your eligibility for learning disabilities services through Disabled Student Services Learning Disabilities Programs. The assessments might include tests of ability, achievement, learning skills and surveys. The results of these tests are strictly confidential. The scores are used in the determination of LD eligibility and in the development of appropriate educational programs. The scores may be maintained in computer files in addition to the test booklet. Descriptive information and test scores maybe used in research projects approved by the Chancellor s Office. To ensure your privacy, this information will not be personally identifiable. If you have any questions, ask for clarification. In addition, if you believe that the assessment or eligibility determination is invalid, you may challenge the results through a petition process. The Information Practices Act of 1977 (Civil Code Sections 1798, et seq.) and the Federal Privacy Act (Public Law 93-579) require that this notice be provided when collecting personal information from individuals. The Community College District and the State of California use information requested on this form for the sole purpose of identifying the student authorized to receive special services. Personal information recorded on this form will be kept confidential in order to protect against unauthorized disclosure. Portions of this information may be transferred to other state and public agencies; however, disclosure to these parties is done in strict accordance with current statutes regarding confidentiality. Providing personal information is strictly voluntary. By signing this consent form you agree to participate in the assessment activities described above and acknowledge the use of the information as described. I understand this information and agree to complete the assessment to determine eligibility for learning disabilities services. Yes No Print Name ID# Signature Date Parent s signature (for students under 18) 12

Learning Disability Information FAMILY HISTORY Does anyone in your family have a learning problem? Yes No * If yes, describe Does anyone in your family have any other type of disability (e.g., physical, emotional, vision or hearing impairment)? Yes No * If yes, describe Describe any family or personal issues, which you feel, have affected your learning in the past. Describe any current family or personal issues that are impacting your education at this time. DEVELOPMENTAL HISTORY Were there any medical or developmental problems before, during, or after your birth? * If yes, explain To your knowledge, was there anything unusual about your early development, e.g., delayed speech; late crawling or walking; problems using scissors, printing, or writing? Yes No Yes No * If yes, explain 13

In what academic areas have you experienced difficulty? (check all that apply) Reading Spelling Math Taking tests Study skills Reading rate Comprehending concepts Retaining information Completing assignments on time Organizing written work Self-confidence in school Motivation Describe your difficulties * Have you discussed your difficulties with your instructor? Yes No NOTES: 14

ALLAN HANCOCK COLLEGE LEARNING ASSISTANCE PROGRAM APPLICATION FOR SERVICES Learning Assistance Program Initial Date of Application for LAP Services: ID#: Name: Telephone #: LAP Program Overview: Allan Hancock College provides educational services and access for eligible students with documented disabilities who intend to pursue coursework at Allan Hancock College. A variety of programs and services are available which afford eligible students with disabilities 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 the Learning Assistance Program (LAP). Student Responsibilities: 1. I will provide the Learning Assistance Program with the information, documentation and/or forms (medical, educational, etc.) deemed necessary by the LAP to verify my disability(ies). 2. I will meet with a Learning Assistance Program professional to complete a Student Educational Contract, and agree to meet with the professional at least annually to update the Student Educational Contract. 3. I will utilize the Learning Assistance Program in a responsible manner. I understand that the Learning Assistance Program uses written service provision policies and procedures that must be adhered to for continuation of services. 4. I will comply with the Student Code of Conduct adopted by the college. I understand that I must fulfill the requirements for participation in the Learning Assistance Program. I have received a copy of the policy on suspension of LAP services, and I understand the consequences of failing to comply with the rules for responsible use of the LAP services. I understand that I will be notified in writing before any action is taken to suspend services. By signing this application I affirm that I understand and agree with the LAP Program responsibilities of students and I will abide by them. LAP Specialist Signature Student Signature Date Date The Community College District uses the information requested on this form for the purpose of determining a student's eligibility to receive authorized special services provided by the Learning Assistance Program (LAP). Personal information recorded on this form will be kept confidential in order to protect against unauthorized disclosure. Portions of this information may be shared with the Chancellor's Office of the California Community Colleges or other state or federal agencies; however, disclosure to these parties is made in strict accordance with applicable statutes regarding confidentiality, including the Family Educational Rights and Privacy Act (20 U.S.C. 1232(g)). Pursuant to Section 7 of the Federal Privacy Act (Public Law 93-579; 5 U.S.C. 552a, note), providing your social security number is voluntary. The information on this form is being collected pursuant to California Education Code Sections 67310-67312, and 84850; and California Code of Regulations, Title 5, Section 56000 et seq. OFFICE USE ONLY Application Processed by: Summer Comments: Fall Spring 15

Allan Hancock College Learning Assistance Program INTAKE SCREENING FOR PHYSICAL DISABILITIES To be completed by LAP staff Name Social Security Number Disability: Blind Arthritis Multiple Sclerosis Partially Sighted Cardiac Disease Paraplegic Deaf Asthma Psychological Hard of Hearing Post Polio Quadriplegic Orthopedic Cerebral Palsy Acquired Brain Injury Speech Disorder Epileptic Other Services Requested: (To be completed by LAP staff) Special Orientation Counseling Note taking Assistance Tape Recorder Interpreter Large Print Materials Tutoring Mobility Assistance Recorded Texts Adapted P.E. Special Parking Print Magnifier FM System Registration Assistance Testing Accomm. Elevator Access Computer Access Other 16

Physical Disability Information How does your disability or disabilities affect your daily life or school experience? Please check all boxes that apply, or that you think will apply to your situation. I have problems writing or typing... I have problems walking distances or climbing stairs... I regularly use a wheelchair or scooter... It takes a long time for me to process and act on information... I am deaf and use sign language interpreters in school... I don t hear well... I have chronic pain and it affects my concentration... I have had a head injury or stroke... I have trouble using regular printed material, or reading from the computer screen... I am legally blind... I am blind and use recorded material and Braille materials regularly... I have a seizure disorder... I have difficulty adjusting to new situations on campus... I frequently experience feelings of anxiety... I find attending class regularly and on time to be a challenge... Communicating with my instructors and classmates is hard for me... Name of Physician, Therapist, or other referring Professional Phone Fax Address City Zip 17

Allan Hancock College Learning Assessment Survey by Margaret Tillery and Paul Fahey Student s Name: ID #: Date Age: - The questions in this survey have NO right or wrong answers. - The best answer is the one that correctly describes you. - Clearly circle your answer to each question. - There is no time limit, but it is best to work quickly. Reading Scale: 1. I read more slowly than most of my classmates. 2. I have to read things three or four times before I understand what I read. 3. I have trouble remembering what I just read. 4. I have trouble answering questions about what I read. 5. I have trouble sounding out new words. 6. I confuse similar words like where and were. Written Language Scale: 1. Spelling is hard for me. 18

2. I have trouble using correct grammar when I write. 3. When writing, I have trouble knowing where or how to begin. 4. Even when I know what I want to say, I have trouble putting my ideas into writing. 5. I have poor handwriting. 6. I have trouble with in-class writing assignments. Oral Language Scale: 1. I have trouble following oral directions. 2. I don t do as well on tests that are based mainly on class lectures. 3. I have trouble finding the right words to express my ideas when I am speaking. 4. I don t understand big words as well as most of my classmates. 5. I have trouble saying words correctly. 6. I have trouble remembering what I hear in lectures. 19

Math Scale: 1. I have trouble remembering basic math facts like the higher multiplication tables. 2. I tend to reverse numbers. 3. I confuse operational symbols like + and - signs. 4. I have trouble understanding abstract math concepts. 5. I have trouble with word problems. 6. I have trouble remembering the steps in math procedures. Study Skills Scale: 1. I have trouble getting organized. 2. I am late for class or work. 3. I have trouble getting started on assignments. 4. I have trouble keeping a regular study schedule. 20

5. I have trouble taking notes in class. 6. I run out of time and have to rush to finish an assignment. Attention Scale: 1. I make careless errors in my class work. 2. I have trouble following through and finishing projects. 3. I am easily distracted by noise or events. 4. I lose things I need like papers, keys, or tools. 5. I forget appointments. 6. I try harder but get less done than other students. STOP Scale Scores: Reading Written Language Oral Language Math Study Skills Attention Total Score 21

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