Investigating a Possible LD/ADHD/ASD

Investigating a Possible LD/ADHD/ASD

Student Accessibility Services (SAS) offers screenings to York students who are experiencing academic difficulties and who suspect these difficulties are due to an undiagnosed Learning Disability (LD), Attention Deficit Hyperactivity Disorder, (ADHD) and/or Autism Spectrum Disorder (ASD). These screenings are designed to help determine if a student should be referred to a psychologist or a psychiatrist in the greater Toronto area for an assessment. The screening/assessment process normally takes 1 to 2 academic terms.

Things you should know ("check" the box once you have read the statement): *

Things you should know ("check" the box once you have read the statement): This process is available to York students who are having difficulty meeting the requirements of their academic program. As part of the screening process, you may be asked to provide copies of your university transcripts and elementary and high school report cards (whenever possible). If the results of the screening indicate that you should be assessed for a LD/ADHD/ASD, it may take between an academic semester (3 months) and a full academic year (6 months) for the assessment to be completed. If you are referred for an assessment, partial or full funding may be available to cover the cost. Please note, there is limited or no funding available to students in their final academic year (60 credits towards an ordinary undergraduate degree, 90 credits towards a honours degree). To determine whether or not you qualify for funding, you may be required to apply for OSAP and/or check with your insurer to see whether extended health benefits provide coverage for psychological services.
Date Date / MM / DD YYYY
What is your main campus? *

What is your main campus? Keele Glendon Satellite
Name Name * First Last
Student Number *
Email address that we can contact you at (does not have to be your York email). Please note, "HOTMAIL" accounts/messages often get flagged as junk mail and messages can be lost. *

Be sure to give us an email address that you check on a regular basis - this is how we will contact you after we receive your form.
Cell Phone Cell Phone * - ### - ### ####
Can we leave messages at this number? *

Can we leave messages at this number? Yes No
Have you ever had testing for learning difficulties, an Individual Education Plan (IEP) or previous academic accommodation? Please provide details. *
Are you currently receiving OSAP? *

Are you currently receiving OSAP? Yes No
Are you currently enrolled in classes? *

Are you currently enrolled in classes? Yes No
Level of Study *

Level of Study Undergraduate Masters Doctorate Certificate
What program are you in? *
How many credits have you completed toward your degree? *
How many credits do you customarily complete per year? *
Who referred you? (e.g. self or other) *
What learning problems are you experiencing? *
Are these problems recent or longstanding? *
What have you tried to address your difficulties? *
Are there currently any problems with your academic standing? What are your grades/GPA? *
Have you failed any courses? If so, how many? *
How would you rate your learning skills and habits? *

How would you rate your learning skills and habits? Poor Average Good
Do you currently have a diagnosed emotional or psychological condition (e.g. depression, anxiety)? *
If yes, are you registered with Student Accessibility Services?
Is English your second language? *

Is English your second language? Yes No
If yes, how long have you been speaking/reading English?
Did you have any academic problems or extra assistance in elementary school? If so, please be specific. *
Did you have any academic problems or extra help in high school? If so, please provide details. *
What was your average when you graduated from high school? *
Have you ever failed a course because you did not complete or submit assignments?

Have you ever failed a course because you did not complete or submit assignments? Yes No
Do you experience any specific difficulties on exams? Please describe.
Does anyone in your family have learning difficulties? If so, is it diagnosed? *
How were you hoping an assessment might help you? *