Learning Disability Assessment Screening Student Name:Date of Birth:Student ID Number:Phone Number:Palomar Student Email: Enter Palomar Student Email Confirm Palomar Student Email The Learning Disability Specialist will be using the student's Palomar student email address to contact them. Be sure to check they check their student email frequently.Address: Street Address City State / Province / Region ZIP / Postal Code Who Referred the Student for Possible LD Assessment?:What is the Student's Educational Goal?:How Many Semesters has the Student Attended Palomar?:Is the Student on Academic Probation?: Yes No Prior to Attending Palomar College had the Student Received LD Services or Assessment? Yes No Where and When?:Is Previous LD Verification Available?: Yes No Is the LD Verification in the DRC Database?: Yes No Is Another Disability Verified and Documented in the DRC Database?: Yes No Comments:Submitted By:Lori MeyersLori WaiteLeigh Ann Van DykeDevonay OlsonJane MillsPatty RicksSabrina MenchacaLaura GorhamAlyssa Vafaei Δ
