Referred to Disability Advisor:
Date: _______________________
Last Name: _______________________________________________________________
First Name: _______________________________________________________________
Student Number: __________________________ Age: ______ Gender:
Sessional Address: ________________________________________________________
City: _____________________________________________ Postal Code: ___________
University of Toronto Email Address:
_____________________________________________________________@utoronto.ca
_________________________________________________________@mail.utoronto.ca
(Please confirm that your University of Toronto e-mail address ends in either @utoronto.ca or @mail.utoronto.ca)
Telephone:
Type: Phone Number: Session(s): May we leave a message?
Primary
 Home  Work
 Cell  Pager
(_______)
________________________


Sessional
Permanent


Yes  No
Name & phone # only.
Alternate
 Home  Work
 Cell  Pager
(_______)
________________________


Sessional
Permanent


Yes

No
Name & phone # only.
Have you used our services before?

Yes

No If yes, who was your primary contact_____________________________,
and when were you here? ________________________________.
What is your current status at the University of Toronto?

Part-Time Student (0.5 to 2.5 courses)

Special Student
 Full-Time Student (3.0 or more courses)  Visiting Student
Undergraduate students: How many credits have you earned?
 0 - 3.5  4.0 - 8.5  9.0 -13.5  14 or more
PLEASE COMPLETE OTHER SIDE OF PAGE
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Access Programs



Academic Bridging Program
Transitional Year Program
Special Student
________________________
St. George Campus
Undergraduate:
Arts & Science
 Innis College
 New College
 Saint Michael's College

Trinity College
 University College
 Victoria University

Woodsworth College
(See also Professional Faculty)
Degree:_________________
Program:________________
________________________
Professional Faculty

Applied Science &
Engineering
 Architecture

Dentistry
 Forestry
Graduate Studies:
Degree:
______________________
Program:
______________________
 Law
______________________
 Medicine
 Music
Stage in program:
 Course work
 Nursing
 Occupational Therapy

OISE/UT
 Pharmacy
 Comprehensive

Thesis
______________________



Physical Education & Health
Physical Therapy
Radiation Science
UTM/UTSC Undergraduate
You must first register with
Accessibility Services on your home campus.
 Arts & Science UTM  Social Work
 Toronto School of Theology
 Arts & Science UTSC
______________________
Degree :
________________________
International Student?
 Yes  No
With which areas do you need assistance?
 Chronic Health Problem (e.g. epilepsy/MS/MD/IBD/Cancer)
 Mobility/Functional Disability (e.g. CP/Polio/RSI)
 Mental Health Condition (e.g. Depression/Bipolar/Anxiety
Disorder/OCD)
 Learning Disability or ADHD
 Brain Injury with Mobility Effect
 Concussion
 Sensory Disability (e.g. Hearing/Vision)
 Temporary
(Please describe):
______________________
 Other (Please describe):
______________________
For Office Use Only: Registration YES  NO  Entered in Database 
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THE INFORMATION ON THIS FORM IS CONFIDENTIAL.
IF YOU NEED ASSISTANCE COMPLETING THIS FORM, PLEASE ASK AT THE FRONT DESK.
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Should you require an assessment, you may choose between having it done by
Accessibility Services or at a private clinic. The fee for the assessment through
Accessibility Services is $2,000. The fee elsewhere is usually higher.
There are several ways payment for this fee can be made:
Bursary For Students With Disabilities
If you have applied for OSAP for the current session and are eligible for a loan, you may be eligible for a bursary to pay for the assessment. (You do not have to negotiate the loan.)
Please note: The bursary fund often runs out early in the year. Please check with the L.D.
Specialist to find out if you should apply for the bursary. The L.D. Specialist has the bursary application form and has to have it approved before it is sent out to Admissions and
Awards. A bursary is non-repayable but is taxable income.
Extended Health Care Plan (For Psychological Services)
You may be covered through a private insurance plan - either your own, your parents', or your spouse's. Please check with your insurance company about coverage. Should you have coverage, let the L.D. Specialist know during your first appointment.
College/Faculty Bursary
This is usually available to students who show financial need and have incurred unexpected expenses. Please check with your College/Faculty about eligibility.
Personal Funds
Please let us know if you are unable to access funding for an assessment through the mechanisms described above. We will work with you to develop a flexible payment plan.
In cases where students demonstrate financial need, a sliding scale is available.
Please do not let the fee for the assessment deter you from going to your initial appointment with the L.D. Specialist. There is no fee to meet with the specialist.
3

Students: Please fill out this form yourself by hand. Do not use a computer.
Name: _______________________________________________________________________
Student Number: _______________________________________________________________
Date of Birth: ___________________________________
College/Programme/Faculty: ______________________________________________________
Full Time ____ Part Time ____ Are you eligible for OSAP? ___________________
How many credits have you earned? _________
Address: ______________________________________________________________________
City: ________________ Province: ______________ Postal Code: _______________
Phone: ____________________________ Can detailed messages be left? __________________
If not, can a name and phone number be left?__________________________
E-mail: ________________________________________________________
High Schools attended: ___________________________________________
High School graduating average: __________
PLEASE ANSWER AS MANY OF THE FOLLOWING QUESTIONS AS POSSIBLE. YOUR
ANSWERS PROVIDE VALUABLE INFORMATION FOR THE LD COUNSELLOR.
1. What are your reasons for contacting Accessibility Services?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
2. Who suggested you come to Accessibility Services?
___________________________________________________________________________
3. Have you had any previous assessments? If so, where and when?
Date: ______________________________________________________________________
Assessed by: _______________________________________________________________
PLEASE ARRANGE FOR COPIES OF PREVIOUS ASSESSMENT REPORTS TO BE
FORWARDED TO THE L.D. COUNSELLOR PRIOR TO YOUR APPOINTMENT.
4

4. Have you ever been told you may have a learning disability? _________________________
By whom? _________________________________________________________________
When?_____________________________________________________________________
5. Have you previously had any special assistance for your learning difficulties (special education, diet, medications, psychological counselling, psychiatric help)? If you wish , please describe below:
Approximate Date Type of Treatment Contact & Phone Number
6. Do you know if there was difficulty during your mother’s pregnancy or childbirth (eg. Diabetes, eclampsia, cord around the neck, breech delivery, lack of oxygen)?
___________________________________________________________________________
___________________________________________________________________________
7. Who helped you with your school-work as a child? (e.g. mother, father, sibling, other)
___________________________________________________________________________
8. Is there any history of school difficulties in your family?
( If you wish to answer this question , please put an X in the appropriate box.)
Mother Father Sister(s) Brother(s)
Other
(specify)
Hyperactivity
Trouble learning to read
Trouble with arithmetic
Trouble with writing
Speech Problems
Behaviour problems in childhood
In trouble as a teenager
Kept back in school
Problems in social relationships
Attention difficulties
Motivational difficulties
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9. Did you enter the University of Toronto:
More than once? __________________________________________________________ a.
After attending another post-secondary institution? ______________________________ b. c. Directly from high school? _________________________________________________ d. e.
1 - 5 years after leaving high school? _________________________________________
6 or more years after leaving high school? _____________________________________
10. a. List any courses failed at any university to date: __________________________________
___________________________________________________________________________ b. Why do you think you failed this/these course(s)? ________________________________
__________________________________________________________________________ c. List all university courses from which you have withdrawn:
___________________________________________________________________________
___________________________________________________________________________
d. Why?___________________________________________________________________
11. Have you been (or are you now) on academic probation/suspension? Please provide details.
___________________________________________________________________________
___________________________________________________________________________
12. What courses are you presently enrolled in?
___________________________________________________________________________
___________________________________________________________________________
13.
How many hours per week do you spend: Number of Hours Spent:
At a paying job?
In activities such as sports, clubs, etc.?
On your school work (aside from classes)?
On family commitments?
On other things?
14. What are your career goals? ___________________________________________________
__________________________________________________________________________
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15. What do you perceive as your learning strengths? __________________________________
__________________________________________________________________________
__________________________________________________________________________
16. What do you perceive as the reasons for your learning difficulties?_____________________
17. How often do you miss going to lectures in a month? _______________________________
18.
__________________________________________________________________________
__________________________________________________________________________
Do you use a computer for word processing? Do you use any adaptive technology (eg. tape recorder, voice-recognition software)? If so, what?
______________________________________________________________________________
______________________________________________________________________________
19. Estimate your present competency for each of the following learning skills. Use a scale of:
1 = Poor, 2 = Average, 3 = Good, N/A = not applicable
Skill Scale
Time Management/ Organizational Skills
Concentration
Note-taking
Reading comprehension/ Comprehension of concepts
Memory
Spelling/Grammar
Handwriting
Essay writing
Writing essay exams
Writing multiple-choice exams
Test review/ Preparation
Controlling exam anxiety
Giving oral presentations/ class presentations
Science/Math problem solving
Learning a foreign language
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20. Did you experience problems in any of the following areas at elementary or high school ?
Please elaborate.
Problem Areas Elementary School High School
Reading
Reading Comprehension
Spelling/Grammar
Handwriting
Essay Writing
Oral Expression (Finding the "right" word/difficulty expressing thoughts or feelings)
Comprehending oral language
Foreign language learning
Math
Memory
Organizational Skills
Time Management
Attention/Concentration
Left/Right confusion
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21. Study Skills and Work Habits
What kind of environment do you prefer to study in (e.g. silence, with television/radio, library, coffee shop)?
__________________________________________________________________________
___________________________________________________________________________
22. Do you experience any difficulty filtering out irrelevant information while studying? ______
23. Do you find that you are easily distracted while reading? ____________
24. Time Management and Organization a. Do you use a daily and semester calendar? _________
Do you have difficulty budgeting time for completing long-term assignments? ________ b. c. Do you have trouble beginning assignments?____________ d. Do you have trouble remembering appointments and arriving promptly? ________
25. Do you have problems with nonverbal communication (reading body language and facial expressions, understanding sarcasm, and humour)? If so, please elaborate.
___________________________________________________________________________
___________________________________________________________________________
26. What types of situations are most difficult for you?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
27. Have your learning difficulties interfered with any aspect of employment?
___________________________________________________________________________
___________________________________________________________________________
28. Have you ever been in an accident and suffered any head trauma?
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29. Have your learning difficulties interfered with any aspect of social or family life?
___________________________________________________________________________
30.
___________________________________________________________________________
What types of strategies have you used to cope with your problems? Which have been the
31. most or least effective?
___________________________________________________________________________
___________________________________________________________________________
Do you drive a car? _______________________________________
If so, have you experienced any difficulties in driving? ___________
32. Do you have any additional questions or concerns?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
THE END
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In order to provide good service Accessibility Services wants students to have trust and confidence in how your information will be used and shared. Staff employed by Accessibility Services regards information we learn about students in interviews, personal communications and/or reports from other professionals as confidential as required by law. We only convey information about the impact of your disability on your learning or your daily needs while on campus with your permission.
The level of information provided is on a need to know bas is meaning that only pertinent information relevant to the current reques t is shared. Your consent may be withdrawn at any time by informing your disability counsellor in writing.
As required by law, Accessibility Services staff will reveal information when:

There is a suspicion of child abuse

A student poses a significant danger to themselves or others

A student reports sexual abuse by a health care professional

It is legally required, for example by subpoena, summons or court order
1.
Please read and provide your written consent below:

I give permission for my disability counselor to view my academic records on ROSI

I understand that test/exam accommodations will be shared with Test and Exam Services at the
Office of Space Management.
2.
In addition to necessary sharing of information among staff at Accessibility Services, I consent to the release and sharing of information with the following:
Initial all that apply:
____ My Registrar at __________________ College
____ Professors in courses I am registered in at U of T
____ Student Health Services
____ Counselling and Psychological Services
____ Academic Progress Team
____ Other _____________________ please specify
Signature __________________________ Date ________________
Witness ___________________________ Date _________________
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