Learning Disability Assessment Self Referral Form Your Name:* First Last Student ID Number:* Date of Birth:* Phone Number:* Palomar Student Email:The Learning Disability Specialist will be using your Palomar student email address to contact you. Be sure to check your student email frequently. Enter Palomar Student Email ONLY Confirm Palomar Student Email ONLY Address: Street Address City State / Province / Region ZIP / Postal Code Who Referred you for Possible Learning Disability Assessment?: What is your Educational Goal?: How Many Semesters have you Attended Palomar?: Are you on Academic Probation?: Yes No Prior to Attending Palomar College did you Receive Learning Disability Services or Assessment? Yes No Where and When?: Is Previous Learning Disability Verification Available?: Yes No Has the Previous Learning Disability Verification Been Given to the DRC?: Yes No Is Another Disability Verified and Documented with the DRC?: Yes No Why do you want to be evaluated for a learning disability?: Δ
