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What Is A Learning Disability?

Adult Testing Application

Adult Testing Application

Adult Testing Application for Learning Disabilities

Step 1 of 9 - General Information

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General Information
Name:*
First Last
Nickname/Name Preferred:
Date of Birth:*
Age:*
Please enter a number from 1 to 100.
Male/Female:*
- Male
- Female
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Referred by: (Facebook, Radio, Staff, Friend, etc.)*

Family History
You grew up in a home with (check all that apply):*
- Birth Father
- Birth Mother
- Step-Father
- Step-Mother
- Adopted
- Legal Guardian
- Foster
- Other
Please explain:*
Did you experience any of the following as a child/adolescent:*
Check all that apply.
- Death in the family
- Separation
- Divorce
- Remarriage of Mother
- Remarriage of Father
- Other major trauma
- None
Please explain:*
Is there a history of learning difficulties in your family?*
- Yes
- No
Please explain:*
Briefly describe your relationship with your family members:*

Medical/Developmental History
Birth History - Were you:*
- Full Term
- Premature
State any known pre-natal complications your mother may have had during her pregnancy with you (e.g., toxemia, diabetes, etc.):
State any complications immediately after birth (e.g., difficulty breathing, blue color, etc.):
Select all that apply:*
- Recent physical exam
- Recent eye exam
- Recent hearing exam
- Recent speech evaluation
- None
Please state the approximate date(s) of the exam(s) and the result(s):*
Check any problems in infancy or childhood with:
- Colic
- Sleeping
- Talking
- Bedwetting
- Crawling
- Eating
- Walking/running
- General slow development
- None
Childhood medical/development issues: (check where applicable)
- Needs glasses
- Wears glasses
- Allergies/asthma
- Seizures, convulsions, or staring spells
- High Fevers
- Frequent ear infections
- Hearing difficulties
- Experienced injury/accident to head
- None
Please explain:*

School History
Name of Elementary School:*
Location*
City State
Grades Attended:*
Do you have additional Elementary Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
Elementary School #2
Name of Elementary School:*
Location*
City State
Grades Attended:*
Do you have additional Elementary Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
Elementary School #3
Name of Elementary School:*
Location*
City State
Grades Attended:*
Do you have additional Elementary Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
Elementary School #4
Name of Elementary School:*
Location*
City State
Grades Attended:*
Do you have additional Elementary Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
Elementary School #5
Name of Elementary School:*
Location*
City State
Grades Attended:*

Junior High/Middle School
Name of Junior High/Middle School:*
Location*
City State
Grades Attended:*
Do you have additional Junior High/Middle Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
Junior High/Middle School #2
Name of Junior High/Middle School:*
Location*
City State
Grades Attended:*
Do you have additional Junior High/Middle Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
Junior High/Middle School #3
Name of Junior High/Middle School:*
Location*
City State
Grades Attended:*
Do you have additional Junior High/Middle Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
Junior High/Middle School #4
Name of Junior High/Middle School:*
Location*
City State
Grades Attended:*
Do you have additional Junior High/Middle Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
Junior High/Middle School #5
Name of Junior High/Middle School:*
Location*
City State
Grades Attended:*

High School
Name of High School:*
Location*
City State
Do you have additional High Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
High School #2
Name of High School:*
Location*
City State
Grades Attended:*
Do you have additional High Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
High School #3
Name of High School:*
Location*
City State
Grades Attended:*
Do you have additional High Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
High School #4
Name of High School:*
Location*
City State
Grades Attended:*
Do you have additional High Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
High School #5
Name of High School:*
Location*
City State
Grades Attended:*

Additional Educational Information
Handedness:*
- Right Hand
- Left Hand
- Uses both hands
- Mirror Writer
Have you repeated any grade(s)?*
- Yes
- No
Please list the grade(s):*
Have you ever received tutoring?*
- Yes
- No
Please list the subjects:*
Have you ever been enrolled in special classes?*
- Yes
- No
Please list the class type(s):*
Have you received physical/occupational therapy?*
- Yes
- No
Have you received speech or language therapy?*
- Yes
- No

What was your BEST subject while attending school?*
What was your WORST subject while attending school?*
Have you ever been tested before?*
- Yes
- No
Date*
Please give the approximate day of the testing.
Location of the testing:*
City State
Have you ever had a:*
- IEP
- 504 Plan
- Other accomodation
Please explain the accommodation:*
Have you been diagnosed with:*
- ADD
- ADHD
- Learning Disabled
- Other
- None
Please explain:*
Additional comments or information regarding school history:
State the area(s) in which you feel you need help:*

Social/Behavioral History
Check where applicable:
- Independent
- Anxious
- Dishonest
- Shy
- Passive
- Lacks common sense
- Easily distracted
- Overly fearful
- Enjoys learning
- Makes friends easily
- Stubborn
- Aggressive
- Withdrawn
- Moody
- Confident
- Dependent
- Complains
- Overly sensitive
- Self-centered
- Easily frustrated
Please list any additional information you would like to share before testing:
I hereby give Joshua Institute consent to test me.*
- Yes

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