Date received____________
Date Interviewed__________
Evaluation Type: ____________
Case Assigned to___________
Fee _______
When Paid _________
How Paid _________
Adult Learning Evaluation Center (A.L.E.C.)
2207 Stone Building
Florida State University
Tallahassee, FL 32306-4464
Phone: 850-644-3611 Fax: 850-645-3308
E-mail: coe-alec@fsu.edu
Application for Services
Are you interested in:
__ Evaluation
__ ADHD Coaching
__ Not Sure
Name
Local
Address
Permanent
Address
Phone number
Home:
Cell Phone:
Work:
ok to leave message at home? Yes___ No___
ok to leave message on cell? Yes___ No___
ok to leave message at work? Yes___ No___
Email address
College attending
Date Enrolled
Major
Estimated College GPA:
Year
___freshman ___sophomore ___junior ___senior ___grad student
Previous
1.
Date_____________
Colleges attended 2.
Date_____________
3.
Date_____________
Previous college
1.
degrees or
2.
certificates
3.
4.
Date of birth
Age
Name of high
school
Date Graduated
Is this a Weighted GPA? YES or NO
Gender
___Male ___Female
Ethnicity
Location of high
school
High School GPA:
Is it on a 4.0 scale or 5.0 scale? 4.0 OR 5.0
2
What college courses are most difficult for you at this time? (e.g., algebra, chemistry)
1.
5.
2.
6.
3.
7.
4.
8.
Please describe the kinds of problems you encounter in these classes (e.g., trouble
remembering formulas; difficulty understanding concepts as they are taught; trouble
remembering ideas, concepts, or facts; anxiety about taking tests, etc.). Please be as
specific as possible.
Have you taken a foreign language in College? ___yes ___no
If yes, which language(s)________________________________
If yes, what grade(s) did you receive in your foreign language class(es)
_________________________________________________.
When did you first have difficulties with schoolwork?
___ Elementary school ___ Middle school ___High school ___ College
Have you taken the SAT? YES / NO
If “yes”, what were your scores? _____Verbal ______Quantitative ____Combined
Have you taken the ACT? YES / NO
If “yes”, what were your scores?
_____English _____Math _____Reading _____ Science _____Composite
Have you taken any other entrance exams? (e.g., GRE, LSAT) YES / NO
Were you required to remediate any subject prior to taking any college level courses?
If Yes, in what subjects? _____English _____Math _____Reading
3
List college courses you have failed or withdrawn from:
Name of course
Number of times
Number of times Failed
withdrawn
How many different schools did you attend from K- 12th grade?
Have you ever repeated a grade?
If yes, which grades?
Have you ever had a psychological or psycho-educational
assessment?
If yes, what grade(s) were you in?
Have you ever been diagnosed as learning disabled?
If Yes, in what subject (i.e. reading, writing, or mathematics)?
As ADHD?
Other diagnosis?
Are you currently taking any ADHD medications?
If yes, which medicine?
Have you ever been placed in a special education classroom?
Describe any academic help (e.g. tutoring) you have had in :
College
___yes ___no
___yes ___no
___yes ___no
___yes ___no
___yes ___no
___yes ___no
___yes ___no
High School
Middle School
Elementary School
What is your primary language?
Are you fluent in a language other than English?
If yes, which language(s)
Which foreign language did you study in high school?
For how many years?
What grade(s) did you receive in your high school foreign
language class(es)?
Did you fail any math classes in high school?
If yes, which courses were they? (algebra, trig, etc.)
___yes ___no
___ yes ____no
4
Has anyone in your family:
-been diagnosed as learning disabled?
-been diagnosed as ADHD?
-had learning difficulties?
___yes ___no
___yes ___no
___yes ___no
Do you suspect any problems with your hearing or vision?
If yes, please explain:
___yes ___no
Symptom Checklist
Review of Symptoms:
Please indicate which of the following is currently, OR has been a problem:
In general
When studying, taking tests,
or thinking about academics
Symptom
Yes
No
Yes
No
Nausea or stomachaches
Difficulty following instructions
Depressed mood
Easily distracted
Restless
Careless
Feeling of losing control
Poor concentration
Anxious or worried
Cannot sit still, fidgets
Feeling hopeless
Poor organizational skills
Palpitations, increased heart rate
Act as if “driven by a motor”/have
non-stop energy
Irritable
Trembling or shaking
Forgetful
Difficulty sleeping
Act without thinking, impulsive
Fails to finish tasks
Talks excessively
Shortness of breath, dizziness
Feel sluggish, low energy, or fatigued
Difficulty sustaining attention
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5
Describe any serious accidents or injuries you have had, with age at the time of the
accident, and describe any consequences (e.g., social, physical, emotional, academic,
or behavioral) of the head injury.
What are your academic strengths? (either specific courses or things you do well)
Who referred you to the Adult Testing Center? (check one)
_____ Advisor/Counselor: Name and Department: __________________________
_____ Parent
_____ Friend
_____ Website
_____ FSU Health Services
_____ Student Disabilities Resource Center (SDRC)
_____ Yellow/White Pages
_____ Other: __________________
Please sign the following statement:
I _________________________________, understand that I may be called to make an
appointment for an evaluation at the Adult Learning Evaluation Center. If I schedule an
appointment and am unable to appear, I agree to call at least 24 hours in advance of my
appointment time. If I do not show up and do not call at least 24 hours in advance,
I agree to pay a cancellation fee of $50.00 and understand that I will likely not be
rescheduled. I understand that if I am an FSU student and do not pay this fee; a stop
will be placed on my record that will prevent me from registering for classes, obtaining
grades, or receiving transcripts.
_______________________________
Signature
___________________
date
For Official Use Only:
__ Late Cancellation Fee
__ 4 to 6 weeks
__ Prior testing?
__ Transcripts
__ Other forms
6
RELEASE OF INFORMATION
I hereby give permission for the Adult Learning Evaluation Center of Florida State
University to communicate with and/or release a copy of my psycho-educational report to the
following persons or agencies:
(1)_________________________
_________________________
_________________________
_________________________
(2)_________________________
_________________________
_________________________
_________________________
(3)_________________________
_________________________
_________________________
_________________________
________________________________________
Client Signature, Date
________________________________________
Witness Signature, Date