School-Age Learning Disabilities Screening Form
Student Information
Student Name
Date of Birth
Grade
School
Teacher
Areas of Concern
Reading difficulties
Writing difficulties
Math difficulties
Attention/concentration issues
Memory problems
Language/communication
Other
Describe specific concerns
Developmental & Medical History
Significant medical or developmental issues
Academic Performance
Academic strengths
Academic challenges
Behavioral/Social Observations
Behavioral/social concerns
Previous Interventions
List previous interventions or supports provided
Additional Comments