Request for Consultation with Psychology Team

Request for Consultation with Psychology Team

Student Accessibility Services (SAS) in partnership with Student Counselling, Health & Well-Being (SCHW) offers consultations to York students who have never been assessed and are experiencing academic difficulties and suspect that these difficulties are due to an undiagnosed attention disorder, mental health disability or learning disability.

If you have been previously assessed and a mental health, learning, attention, medical, sensory or physical disability was diagnosed, (even if your reason for looking into a consultation is to explore a different diagnosis), please visit the New to our Office page of our website for information about how to register with us.

Consultations are booked for 1 hour and can be done in-person or virtually. If you choose to meet virtually, we do require that you have access to a camera and that the camera is on.

This form gathers information so that we can assist you in deciding "next steps" and direct you towards supports and services.

Date Date / MM / DD YYYY
What is your goal in reaching out for a consultation: *

What is your goal in reaching out for a consultation: Information about assessment options and costs Information about mental health and wellness supports Information about academic supports Information about financial supports Information about career supports
What is your main campus? *

What is your main campus? Keele Glendon Markham Satellite
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? *
Do you have access to a medical doctor? *

Do you have access to a medical doctor? Yes No
What academic difficulties are you experiencing? *
Have you spoken with your doctor about the difficulties you are experiencing?

Have you spoken with your doctor about the difficulties you are experiencing? Yes No
Are these difficulties recent or since childhood? *
How have you tried to address your academic difficulties? *
Have you done poorly in any courses at York (or another post-secondary institution)? *

Have you done poorly in any courses at York (or another post-secondary institution)? Yes No
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
How would you rate your learning skills (e.g. time management, prepping for exams, notetaking)? *

How would you rate your learning skills (e.g. time management, prepping for exams, notetaking)? Poor Average Good
Did you have any academic difficulties or receive extra assistance in elementary or high school? *

Did you have any academic difficulties or receive extra assistance in elementary or high school? Yes No
If YES, please provide details:
Have you ever had difficulties with the following? Please check all that apply.

Have you ever had difficulties with the following? Please check all that apply. Hearing Vision Sleep Migraines Mental health Attention/concentration Heath Concerns Drug or alcohol abuse Other Other
Please share how your learning was impacted:
Stress, mood, and anxiety can have a broad range of effects on academic success. This impact can range from struggles with focus and concentration to trouble getting down to work. Student Counselling, Health & Well-Being (SCHW) provides wellness and personal counselling support to York students. Visit the SCHW website to learn more.
Are you having any difficulties with stress, anxiety, depression or other emotional/psychological concerns? *

Are you having any difficulties with stress, anxiety, depression or other emotional/psychological concerns? Yes No I'm not sure
Please elaborate:
Have you spoken with your doctor about your mental health concerns?

Have you spoken with your doctor about your mental health concerns? Yes No
Did you have trouble learning to read, spell or do math? *

Did you have trouble learning to read, spell or do math? Yes No I don't know
Please elaborate:
Did you have difficulties with short attention span, concentration or restlessness as a child? *

Did you have difficulties with short attention span, concentration or restlessness as a child? Yes No I don't know
Please elaborate:
Do you experience any of the following? Please check all that apply. *

Do you experience any of the following? Please check all that apply. Lack of motivation Low energy Difficulties attending lectures Difficulties paying attention during lectures Feeling nervous, restless or tense Meeting deadlines None of the above
Have you accessed any of the supports listed below? Please check all that apply. *

Have you accessed any of the supports listed below? Please check all that apply. Medication Counselling Assistive Technology (e.g. reading software, recording tools) Tutoring or extra help in school None of the above
Have you ever completed a formal assessment of your needs (e.g. reading, speech)? Does anyone in your family have learning difficulties? If so, have they been diagnosed with a disability? *
Who referred you to our office? (e.g. self or other) *
Please indicate your availability Monday through Friday from 9am to 4pm:

Consultations are booked for 1 hour and can be done in-person or virtually. If you choose to meet virtually, we do require that you have access to a camera and that the camera is on.
You are aware that if you are meeting virtually that your camera must be on in-order-to complete the consultation. *

You are aware that if you are meeting virtually that your camera must be on in-order-to complete the consultation. Yes
SAS offers consultations in partnership with SCHW. We respect your privacy and will keep your information confidential, however, information may be shared between SAS and SCHW for the purpose of supporting you with engaging in resources through our offices. If you have any questions, please send an email to sasreg@yorku.ca