LSE Disability and Well-being Service 2014/15
Neurodiversity Service Screening Form
Step 1 - Complete this confidential form online
Step 2 - Email it to Disability-dyslexia@lse.ac.uk
Step 3 - Recommended: Get your eyes tested by an optometrist prior to meeting
Step 4 - Bring a piece of handwritten text to the meeting
Name Click here to enter text.
Date Click here to enter text.
Student number Click here to enter text.
Email Click here to enter text.
Mobile number Click here to enter text.
Address Click here to enter text.
Date of birth Click here to enter text.
Country of birth Click here to enter text.
First language Click here to enter text.
If your first language is not English:
1. How many years have you spoken English? Click here to enter text.
2. What other languages do you speak and to what level? Click here to enter text.
Your course Click here to enter text.
Year of study Click here to enter text.
Full or part time? Click here to enter text.
Date of last eye test? Click here to enter text.
What are your concerns at the moment?
Click here to enter text.
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LSE Disability and Well-being Service 2014/15
Neurodiversity Service Screening Form
Please give details where possible in the following sections.
Family background and your early development
Do any of your family (close or extended) have:
☐Dyslexia? Click here to enter text.
☐Dyspraxia? Click here to enter text.
☐ADD or ADHD? Click here to enter text.
☐Autism?
Click here to enter text.
☐Literacy/language difficulties? Click here to enter text.
☐Numeracy/maths difficulties? Click here to enter text.
☐I don’t know Click here to enter text.
Were you:
☐late in learning to talk? Click here to enter text.
Did you:
☐have therapy for speech difficulties? Click here to enter text.
Education
As a young person, did you experience delay or difficulties in:
☐Learning to read? Click here to enter text.
☐Learning to spell? Click here to enter text.
☐Writing by hand? Click here to enter text.
☐Reading aloud? Click here to enter text.
☐Doing maths? Click here to enter text.
☐Mental arithmetic? Click here to enter text.
☐Memorising your times (multiplication) tables? Click here to enter text.
☐Concentration? Click here to enter text.
☐Passing exams? Click here to enter text.
☐Learning to use a computer? Click here to enter text.
☐Learning additional languages? Click here to enter text.
Did you
☐miss any schooling or have interruptions to schooling? Click here to enter text.
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LSE Disability and Well-being Service 2014/15
Neurodiversity Service Screening Form
☐have any additional tutoring at school? What kind? Click here to enter text.
☐find some subjects very easy? Which ones? Click here to enter text.
Medical and developmental information
-Give details of any of the following (past or present):
☐Significant illnesses, accidents or disabilities Click here to enter text.
☐Hearing problems Click here to enter text.
☐Vision problems Click here to enter text.
☐Mobility problems Click here to enter text.
☐Hand-eye coordination difficulties Click here to enter text.
Were you slow to learn how to:
☐Tie your shoelaces? Click here to enter text.
☐Catch a ball? Click here to enter text.
☐Tell the time? Click here to enter text.
☐Remember left and right? Click here to enter text.
Were you:
☐considered to be a clumsy child? Click here to enter text.
Do you:
☐play or do sport? Which ones, to what level?Click here to enter text.
☐have very flexible joints? Click here to enter text.
☐trip over or bump into or spill things? Click here to enter text.
Listening and Speaking
Is it hard:
☐to pronounce words, especially long ones? Click here to enter text.
☐to make good/complete notes in lectures? Click here to enter text.
☐to find the right word, even if it’s on the tip of your tongue?Click here to enter text.
☐to express yourself verbally in seminars? Click here to enter text.
Do you:
☐often interrupt other people? Click here to enter text.
☐often finish other people’s sentences? Click here to enter text.
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LSE Disability and Well-being Service 2014/15
Neurodiversity Service Screening Form
☐lose track of conversations when socialising? Click here to enter text.
Reading and research
Do you:
☐need to re-read text several times over for comprehension? Click here to enter
text.
☐quickly forget what you have just read? Click here to enter text.
☐find it hard to pronounce unfamiliar words? Click here to enter text.
☐find it difficult to read on computer screen? Click here to enter text.
☐get eye strain or headaches when reading? Click here to enter text.
☐find it hard to take notes when reading? Click here to enter text.
Academic writing
Do you have difficulties with:
☐structuring your essays? Click here to enter text.
☐expressing your ideas well in writing? Click here to enter text.
☐spelling? Click here to enter text.
☐grammar, punctuation & sentence structure? Click here to enter text.
☐proofreading & seeing your own errors? Click here to enter text.
☐meeting submission deadlines? Click here to enter text.
Memory and recall
Do any of these statements apply to you?
☐My long term memory is good Click here to enter text.
☐I have to write everything down otherwise I forget it Click here to enter text.
☐I remember faces but not names Click here to enter text.
☐I am always losing things or leaving them behind somewhereClick here to enter
text.
☐I take much longer to revise for exams than my fellow-students do Click here to
enter text.
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LSE Disability and Well-being Service 2014/15
Neurodiversity Service Screening Form
Exams
Please list exam subjects and grades since 16 years old
Secondary School Click here to enter text.
Under-graduate Click here to enter text.
Post-graduate Click here to enter text.
Other Click here to enter text.
Do these statements apply to you? If yes, give details:
☐I have had exam accommodations before (eg. extra time)Click here to enter text.
☐I get better grades for coursework than for examsClick here to enter text.
☐I have failed and/or resat an exam Click here to enter text.
☐My handwriting is untidy in exams Click here to enter text.
☐I get cramp in my writing hand/arm Click here to enter text.
☐I usually run out of time in exams Click here to enter text.
Time management and work organisation
Do these statements apply to you? If yes, give details:
☐ It’s hard to keep my paperwork and files in order Click here to enter text.
☐ I am often late Click here to enter text.
☐ I often forget appointments or arrangements Click here to enter text.
☐ It’s hard to meet deadlines for submitting coursework Click here to enter text.
Concentration
Do these statements apply to you? If yes, give details:
☐ I am easily distracted (by what?) Click here to enter text.
☐ I ‘zone out’ quickly/often during lectures Click here to enter text.
☐ As a child, I daydreamed in classes Click here to enter text.
☐ I doodle to help with concentration Click here to enter text.
☐It’s hard to finish off or ‘wrap up’ the final details of tasks Click here to enter
text.
☐It’s hard to order and prioritise tasks Click here to enter text.
☐I procrastinate and put off tasks till the last minute Click here to enter text.
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LSE Disability and Well-being Service 2014/15
Neurodiversity Service Screening Form
☐I get restless and fidgety when sitting for a long time Click here to enter text.
☐I feel as if I am driven by a motor or compelled to do things Click here to enter
text.
Anything else you want to add?
Click here to enter text.
See next page for …..
What happens after your screening appointment
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LSE Disability and Well-being Service 2014/15
Neurodiversity Service Screening Form
What happens after your screening appointment
If indicators of dyslexia, dyspraxia or neurodiversity are found during screening:
1. Go to Disability and Well-being Service (Old Building G23)
2. Pay £50 cash and book an appointment (LSE pays the balance of £350)
3. Attend appointment or give 48 hours’ notice of cancellation/reschedule (no
refund of £50)
4. Allow 3 hours for appointment (usually takes place at LSE)
5. Allow 3 weeks for assessment report to reach Disability and Well-being Service
(DWS)
6. As soon as we have your report we will contact you to arrange a meeting with
one of the Neurodiversity team to discuss the report findings
If the diagnostic assessment report confirms dyslexia, dyspraxia or neurodiversity:
1. Attend a meeting with a one of the Neurodiversity team
2. Draw up an Individual Student Support Agreement (ISSA)
3. If you are a home student, apply for Disabled Students Allowance (DSA)
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