Student Accessibilty Services Screening Form

Student Accessibility Services offers screenings to York students are experiencing academic difficulties and suspect that these difficulties are due to an undiagnosed attention disorder, mental health disability or learning disability. In part, these screenings are designed to help students determine "next steps" (our office does not provide diagnostic services). This questionnaire is to gather information, it is not a diagnostic screening tool. It is used with other information, like past report cards, to determine what next steps might be helpful for you.

Sometimes, students contact us about a screening with a history of academic supports or an existing diagnosis. We recommend these students explore Registration with our office (it might not be necessary to complete this Screening Form). If you have questions about registration with our office, please email sasreg@yorku.ca

Things you should know (check the box after you have read the statement). *

Things you should know (check the box after you have read the statement). I understand the Student Accessibility Services does NOT provide diagnostic services.
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If you are referred for a psychoeducational assessment, partial or full funding may be available to cover the cost. Please note, there is limited or no funding available to students in their final academic year (60 credits towards an ordinary undergraduate degree, 90 credits towards a honours degree).
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To determine whether or not you qualify for funding, you may be required to apply for OSAP and/or check with your insurer to see whether extended health benefits provide coverage for psychological services.
Date Date / MM / DD YYYY
What is your main campus? *

What is your main campus? Keele Glendon Satellite
How did you learn about our screening service? *

How did you learn about our screening service? Student Counselling, Health & Well-Being Faculty or Teaching Assistant Academic Advising Found the information online Other Other
Name Name * First Last
York Student Number *
Pronoun(s):
Email address that we can contact you at (does not have to be your York email). Please note, "HOTMAIL" accounts/messages often get flagged as junk mail and messages can be lost. *

Be sure to give us an email address that you check on a regular basis - this is how we will contact you after we receive your form.
Cell Phone Cell Phone * - ### - ### ####
Can we leave messages at this number? *

Can we leave messages at this number? Yes No
Are you currently receiving OSAP? *

Are you currently receiving OSAP? Yes No
Are you currently enrolled in classes? *

Are you currently enrolled in classes? Yes No
How many credits have you completed toward your degree? *
How many credits do you customarily complete each year? *
Have you failed any courses at York (or another post-secondary institution)? *

Have you failed any courses at York (or another post-secondary institution)? Yes No
If yes, how many courses have you failed?
Have you ever failed a course because you did not complete or submit assignments?

Have you ever failed a course because you did not complete or submit assignments? Yes No
Are there any problems with your academic standing at York (e.g. academic warning)? *
Have you been diagnosed with a disability (mental health, medical, physical, sensory, learning or attention in nature) or spoken with a medical professional about a diagnosis? *

Students with existing diagnosis should explore registration with our office. If you are already registered with Student Accessibility Services, please make an appointment with your Accessibility Counsellor to discuss your difficulties.
What difficulties are you experiencing? *
Are these difficulties recent or longstanding? *
How have you tried to address your difficulties? *
How would you rate your learning skills such as time management? *

How would you rate your learning skills such as time management? Poor Average Good
Do you experience any specific difficulties writing tests and exams? If yes, please describe these difficulties.
Did you have any academic difficulties or receive extra assistance in elementary school? If yes, please provide details. *
Did you have any academic difficulties or receive extra assistance in high school? If yes, please provide details. *
What was your average when you graduated from high school? *
Does anyone in your family have learning difficulties? If so, have they been diagnosed with a disability? *
How are you hoping our office might help you? *
Who referred you to our office? (e.g. self or other) *
We are meeting with students remotely, via telephone and video conference. Please indicate your availability during the following times and whether you prefer to meet via telephone or video conference.
Mondays 2:30pm to 3:30pm
Tuesdays 2:30pm to 3:30pm
Thursdays 10am to 11am
Fridays 11am to 12pm *
Notification of How Your Information will Be Used

Student Accessibility Services collects medical documentation and other information pertaining to your functional limitations, your history of learning or personal circumstances for the following purposes:

• To verify the need for disability related accommodations for academic work and
• To develop and implement effective disability related accommodations and supports

Student Accessibility Services respects your privacy and keeps your information confidential. Information may be shared with university staff, but only on a need-to-know basis to allow them to perform their duties and to provide academic or other disability related accommodations on campus.

Examples:
• Test and Exam accommodations will be shared with the Alternate Exam/Test Scheduling for invigilation.
• The name of students with a reduced course load as an accommodation may be shared for fees adjustment purposes or to arrange bursaries.
• Accessibility Counsellors may speak to a professor, registrar or residence staff to arrange accommodations and supports.
• When a student encounters difficulties that require attention from other University units, such as Student Counselling & Development, Students of Concern Committee, Office of Student Community Relations, Residence Life, necessary information is shared with those units.

To protect your information, all university staff receiving information follows University policies and guidelines, the Freedom of Information and Protection of Privacy Act and other legal requirements*.

"Frequently Asked Questions (FAQs) About How Information is Used" is available from our website: https://accessibility.students.yorku.ca/index.php/how-your-information-is-used

If you have any questions, please send an email to sasreg@yorku.ca. Your email will be forwarded to the Director for follow up as soon as possible.

* Student Accessibility Services provides academic accommodation and support to students with disabilities in accordance with the Ontario Human Rights Commission’s Policy on accessible education for students with disabilities and York University Senate Policy on Academic Accommodation for Students with Disabilities.

Student Accessibility Services at York University is subject to the Freedom of Information and Protection of Privacy Act ("FIPPA") and York University’s Policy on Access to Information and Protection of Privacy. Information is collected under the authority of The York University Act, 1965 to administer the university-student relationship.
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I have read and understand the "Notification of How Your Information Will Be Used".