Speech, Language and Learning Information Please describe your concern about your language, literacy, and/or learning abilities. *
When were your difficulties first noted? *
Has the problem * improved worsened remained the same
Please explain:
Are there situations in which you have particular difficulty? * Yes No
If yes, please describe:
Are you bilingual? * Yes No
Other language:
What is the primary language used at home?
What is the primary language used at work?
How have your language-learning difficulties affected your social interaction with peers? *
Your willingness to talk to others? *
Your participation in the classroom? *
Your academic success? *
Your work performance? *
Do you feel that your self-esteem has been affected by your language or learning abilities? * Yes No
If yes, please describe:
Has your hearing been tested? * Yes No
If yes, please provide date and result of testing:
Please describe what you do well. *
Please describe your interests. *
Please describe your strengths. *
Are you currently enrolled in language therapy and/or tutoring? * Yes No
If yes, has it helped?
# of sessions weekly:
Length of each session:
Please describe any other related services that you currently receive. *
