Writing Disability Diagnostic Interview Form

Personal Information

Full Name Date of Interview Date of Birth Gender Male Female Other Grade / Current Enrollment Interviewer

Background Information

Relevant Medical History Family History of Learning Difficulties Languages Spoken at Home

Educational History

Schools Attended Previous Evaluations/Diagnoses Special Services/Supports Received

Writing Difficulties Detail

Areas of Difficulty (Check all that apply)

	Yes	No
Spelling
Handwriting
Grammar
Punctuation
Organizing Ideas
Sentence Structure

Other Concerns

Sample Questions

When did you first notice writing difficulties? Describe a typical writing task that is challenging. How do these difficulties affect school/home life? What strategies have been tried to overcome these difficulties?

Observations & Notes

Observational Notes Additional Comments