Client Information Form For Student Access & Disabilities

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Pickler MemorialLibrary 109A100 East NormalKirksville, MO 63501Office of Student Accessand Disability Services(660)785-4478 phone(660)785-4490 faxClient Information Form for Student Access & DisabilitiesName:Date:Banner ID Number:Date of Birth:Telephone Number (cell):Telephone (local):Campus Address:E-mail Address:Year in School: Freshman Sophomore Junior Senior GraduatePersonal InformationMy major isMy GPA isEnglish is my 1st language: Yes No, my first language is On probation Progressing as expectedI am currently: Progressing worse than expected Progressing better than expected1. Please describe why you contacted the Office of Student Access and Disability Services/what is the barrier youare experiencing accessing your classroom education:2. I work while attending school (if yes, describe your position and indicate how many hours you work perweek): Yes No3. There have been significant changes in my life during the past year (if yes, please provide additional details): Yes No

Educational Information1. Have you ever repeated a grade? Yes NoIf yes, please list the grade(s):2. Have you ever skipped a grade? Yes NoIf yes, please list the grade(s):3. Have you ever been enrolled in any special education or remedial classes in elementary, middle, or highschool (if yes, please describe)? Yes No4. Have you received accommodations or special services at a high school, college or university (if yes, pleasedescribe)? Yes No5. If you have not received accommodations previously, what accommodations are you requesting to remove abarrier to allow access to the classroom/curriculum?:6. Have you ever been suspended (if yes, please provide details)? Yes No7. Have you ever been on academic probation (if yes, please provide details)? Yes No8. List the high schools and colleges you have previously attended:SchoolCity9. ACT/SAT Scores:Dates AttendedDegree EarnedGPAGraduate Test Scores (GRE, GMAT, etc.):History and Nature of Disability1. Have you ever been diagnosed with a learning disability? Yes NoIf yes, when?2. Describe your learning difficulties or academic challenges and accommodations that have helped in the past:

3. Indicate the area(s) in which you experience academic difficulty: Reading Writing Mathematics Spelling Note taking Handwriting Other, pleasedescribe:When did you first notice these difficulties?4. Describe any difficulties you experience concentrating or paying attention:5. Indicate the area(s) in which you experience difficulty: Memory Organization Time Management Planning Initiating Tasks Other, pleasedescribe:When did you first notice these difficulties?6. Describe your academic strengths:7. On average, how many hours per week do you study? Less than 10 10 – 15 15 – 20 20 – 25 25 – 30 30 – 35 More than 358. How would you rate your study skills? Below average Average Above average9. How much effort do you put into studying? Below average Average Above average10. Do you believe there is room for improvement in your class attendance? Yes No11. Please describe other demands on your time (such as internships, family, activities, athletics, fraternities,sororities, etc.):Family Educational History1. Has anyone in your family been diagnosed with a learning disability (if yes, please provide details)? Yes No2. Has anyone in your family been diagnosed with ADD or ADHD (if yes, please provide details)? Yes No

3. Please list the education levels and occupations of your parents and siblings:Highest Education LevelCurrent OccupationMotherFatherSiblingSiblingSiblingMedical History1. To your knowledge, did you experience any trauma or complications at birth (if yes, please provide details)? Yes No2. Did you have any major childhood illnesses, diseases, or surgeries (if yes, please provide details)? Yes No3. Have you ever been diagnosed with a psychiatric disorder (if yes, please provide details)? Yes No4. Have you in the past or are you currently receiving formal counseling (if yes, please provide details)? Yes No5. Have you ever experienced head trauma and/or lost consciousness (if yes, please provide details)? Yes No6. Have you ever had a seizure (if yes, please provide details)? Yes No

7. Are you currently being treated for any medical condition (if yes, please provide details)? Yes No8. Have you ever been diagnosed with ADD or ADHD (if yes, please provide details)? Yes No9. Are you currently taking any prescription medications (if yes, please provide details)? Yes No10. Do you have any significant vision problems (if yes, please provide details)? Yes No11. Do you have any significant hearing problems (if yes, please provide details)? Yes No12. How many alcoholic beverages do you drink per week?Student’s SignatureDate

Client Information Form for Student Access & Disabilities Personal Information My major is My GPA is English is my 1st language: Yes No, my first language is I am currently: On probation Progressing worse than expected . Progressing as expected Progressing better than expected . 1. Please describe why you contacted the Office of Student Access .

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