Dyslexia Screening Student Intake Form
Dyslexia Screening Student Intake Form
UCD Dublin
Access Centre Disability Support
James Joyce Library, Level 1
Belfield
Dublin 4
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Dyslexia Screening Student Intake Form
The information contained in this form is strictly confidential
Dear Student,
We at the Access Centre would like to welcome you to participate in the Access Centre Dyslexia
Screening service. This service is available to all registered students at UCD. Students may self-refer or
attend as the result of a referral from a source within UCD. This form is used solely for the purposes of
providing an initial indicator for dyslexia and does not constitute a diagnosis or entitle the student to
supports from UCD Access Centre Disability Support. Your form will be reviewed and if it is deemed
necessary that further assessments are needed, you will be asked to make an appointment for further
screening.
The first part of the screening process is the ‘Dyslexia Screening Student Intake Form’. It is your
responsibility to complete the form and return it in a timely fashion to UCD Access Centre Disability
Support office with any relevant supporting documents. Please complete the form in your own
handwriting. If you have any questions about this form please do not hesitate to make contact with the
Access Centre on 01 716 7565.
INSTRUCTIONS FOR COMPLETING FORM

It is your responsibility to complete this form and return it within two weeks, with any relevant
documents, to the Access Centre Disability Support Office.

You may need to consult with parents and family members in order to answer some of the
questions.

If you have received this form in an email or downloaded it from the Access Centre website
please print it and complete the form in your own handwriting.

All information contained in this form is confidential and compliant with Data Protection Acts.
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Dyslexia Screening Student Intake Form
Please fill in the information below
Contact Information
1. Student Name:
2. Student Number:
3. Date of Birth:
4. Age:
5. Male/Female:
6. Home Phone:
7. Mobile Phone:
8. UCD email
9. Term Address:
10. Permanent Address
Current Academic Information
1. What is your Programme
of Study?
2. Please fill in the modules
you are currently taking:
1.
2.
3.
4.
5.
6.
3. Are you studying at
undergraduate or
postgraduate level?
 Undergraduate
 Postgraduate
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Dyslexia Screening Student Intake Form
4. What year are you in?
5. Who referred you for
screening?
 1st

2nd

3rd

4th
 Self
 Lecturer/Tutor
 Student Health
 Student Advisors
 Other ________________________
6. Please tick any difficulties
(as related to learning)
that you are currently
experiencing.
 Note-taking
 Time needed to complete assignments
 Spelling
 Study Skills
 Speed of reading/writing
 Listening Comprehension
 Essay Writing
 Time Management
 Other__________________________
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Dyslexia Screening Student Intake Form
7. While studying at UCD
have you accessed any of
the following:
 Assistance from Lecturers/tutors
a) Very Helpful
b) Helpful
c) Not Helpful
 Academic Writing Centre
d) Very Helpful
e) Helpful
f)
Not Helpful
 Maths Support Centre
a) Very Helpful
b) Helpful
c) Not Helpful
 Study Skills Modules
a) Very Helpful
b) Helpful
c) Not Helpful
 Grinds
a) Very Helpful
b) Helpful
c) Not Helpful
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Dyslexia Screening Student Intake Form
 Assistance from Family or Friends
a) Very Helpful
b) Helpful
c) Not Helpful
8. Compared to your
classmates, does it take
you more time to
complete readings and
assignments?
 Yes
9. How often do you attend
the following?
1. Lectures
 No
 Always
 Sometimes
 Rarely
2. Tutorials
 Always
 Sometimes
 Rarely
3. Practical Labs
 Always
 Sometimes
 Rarely
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Dyslexia Screening Student Intake Form
10. Did you attend any
other third level
college prior to UCD?
 Yes
 No
If yes, please state the college and how long you attended:
__________________________________________________________
STRATEGIES FOR ACTIVE LEARNING
Please tick
1. I am determined. I work
hard to find ways to
succeed.
 Never
 Sometimes
 Often
2. I will work for long
periods of time on
problems.
 Never
 Sometimes
 Often
3. I seek help when I don’t
understand coursework.
 Never
 Sometimes
 Often
4. I work much harder than
my peers.
 Never
 Sometimes
 Often
5. I often stay in and study
rather than socialising.
 Never
 Sometimes
 Often
6. I know how I learn best
and when I learn best.
 Never
 Sometimes
 Often
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Dyslexia Screening Student Intake Form
7. When I study I make
summary notes, mind
maps, diagrams, etc.
 Never
 Sometimes
 Often
8. I test my memory and
understanding at regular
intervals when studying.
 Never
 Sometimes
 Often
9. I take regular breaks and
monitor concentration
when studying.
 Never
 Sometimes
 Often
10. I try to attend all lectures
and tutorials.
 Never
 Sometimes
 Often
11. I repeat material aloud to
be memorised, and write
out key points.
 Never
 Sometimes
 Often
EDUCATIONAL HISTORY
1. Have you previously been
assessed for learning
difficulties?
 No
 Yes, if yes by whom?
______________________________
2. Do you have a written
report from this
assessment?
 No
3. How many schools did
you attend as a child?
 Number of Primary Schools ____________
 Yes, if yes please attach.
 Number of Secondary Schools ____________
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Dyslexia Screening Student Intake Form
4. Please list the school(s)
you attended.
1. ________________________________
2. _________________________________
3. ___________________________________
4. Did you repeat a year at
primary or secondary
school?
 Yes
 No
If yes, what years? __________________________
5. Did you experience a
difficulty learning any of
the following in school?
 Reading
 Writing
 Spelling
 Maths
Comment:
____________________________________________________
____________________________________________________
____________________________________________________
6. Did you receive any of the
following at school?
 Special Education Resource Teacher
 Exam Accommodation
 Learning Support
 Extra Tuition
7. Did you require extra help
outside of school?
 Private Grinds
 Family/Friends
 Grind School:____________________________
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Dyslexia Screening Student Intake Form
8. Did you have frequent
and/or extended
absences from school?
 Yes
 No
Comment:
____________________________________________________
____________________________________________________
____________________________________________________
9. Compared to your
classmates, how much
time and effort did you
put into your studies in
secondary school?
 Less time and effort
 The same amount of time and effort
 More time and effort
Comment:__________________________________
___________________________________________
___________________________________________
10. In secondary school what
type of assignments did
you do better on?
 Exams
11. What were you favourite
subjects in school? Please
list.
1. ______________________
 Take home assignments/essays/homework
2. ______________________
3. ______________________
4. ______________________
12. What were your least
favourite subjects in
school? Please list.
1. _______________________________
2. _______________________________
3. _______________________________
4. _______________________________
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Dyslexia Screening Student Intake Form
FAMILY HISTORY
1. Has anyone in your family
been assessed as having a
learning disability?
 No
 Yes, if yes what is the nature of their learning disability?
_____________________________________________
_____________________________________________
_____________________________________________
2. What language is
normally spoken at
home?
3. Is your family bilingual?
________________________________
 No
 Yes
4. Did you attend an all-Irish
or other language school?
 No
5. If you answered yes to
question 4: did you
experience any of the
following?
 Learning to read in your first language
 Yes
 Learning to write in your first language
 Learning maths in your first language
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Dyslexia Screening Student Intake Form
MEDICAL HISTORY
1. Did you reach
developmental
milestones within normal
limits (crawling, walking,
talking etc.
 No
 Yes
 Don’t know
Comment:____________________________________
2. With which hand do you
write?
 Left
 Right
 Both
3. Have you ever had the
following checked?
 Eyesight
 Hearing
TALENT AND ABILITIES
Please rate your ability to do the following activities.
1. Art
 Poor
 Average
 Good
2. Music
 Poor
 Average
 Good
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Dyslexia Screening Student Intake Form
3. Drama
 Poor
 Average
 Good
4. Creative Writing
 Poor
 Average
 Good
5. Dancing
 Poor
 Average
 Good
6. Woodcraft/Crafts
 Poor
 Average
 Good
7. Using a computer
 Poor
 Average
 Good
8. Speaking in public
 Poor
 Average
 Good
9. Other
____________________________________________
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Dyslexia Screening Student Intake Form
ADDITIONAL INFORMATION
Please detail any other
information you feel may be
relevant in the space provided.
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
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