Dear Parents/Guardians:

Aware of the varied personalities and individual differences among learners, Saint Louis University aims to offer relevant
services to meet the diverse needs of its students. In line with this, we would like to request you to give us information
with regard to your child’s/ward’s unique learning needs or concerns.

Your honest response to this survey form shall be taken as an indication of your willingness and commitment in
collaborating with the Administration, Faculty, and Student Support Services in ensuring your child/ward’s holistic
development while in the university. Rest assured that all information will be treated with utmost confidentiality.

The information provided will be used for the proper identification, monitoring, and management of students with
unique learning needs only and shall only be viewed by the attending Guidance Counselor and the Guidance Center
Director. When not required, the paper or files are kept in a locked drawer or filing cabinet. Paper or data printouts are
shredded and disposed of securely when no longer needed. Data that are electronically stored are protected by strong
passwords and can only be accessed by authorized personnel.

Please submit the accomplished form immediately upon completion of the enrollment process.

Sincerely yours,
The Admissions Committee

Name (of Student) _____________________________________________________________________________

( Family Name ) ( First Name ) ( Middle Name )
ID No.: ___________ Course & Year: _________________________
Date of Birth: ____________________ Age: _____ Sex: _______
Instruction: Kindly check  the box that best describes/identifies your child’s/ward’s condition that needs special
attention.
I. Basic Assessment on Students with Unique Learning Needs:

A. Sensory Difficulties
1. Having difficulty seeing faraway objects
2. Having difficulty seeing nearby objects
3. Has blurred vision and difficulty seeing near and far objects
4. Inability to see some of the colors or all the colors
5. Complains of blurred vision, burning or itching of eyes/eyelids or involuntary jerky movements of the eyes
6. Absence of the visual sense, inability to see completely
7. Others, please specify: _____________________________________________________________________

1. Often complains of pain or ringing in the ears or problems in hearing

2. Difficulties in hearing soft sounds. This can be remedied by using hearing aid.
3. Has complete inability to hear sounds
4. Others, please specify: _____________________________________________________________________

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 B. Intellectual Difficulties
1. Has deficits in general mental abilities such as reasoning, problem solving, planning, abstract thinking,
judgment, academic learning, and learning from experience
2. Specific Learning Disorder - Has a persistent and impairing difficulty with learning foundational academic skills
in reading, writing, and/or math
a. Reading, writing, spelling and speaking difficulty with low level of competence compared to most of
his/her age
b. Has difficulty in performing simple Math problems with low level of competence compared to most of
his/her age
c. Has difficulties with motor coordination (tasks such as walking, jumping and fine coordination) when
compared to children of the same age. With this difficulty, he/she may also experience problems with
delayed speech or other speech problems
3. Learning Difficulties - Has scores substantially below achievement scores in standardized tests in math,
reading or written expression compared to the expected level for his/her age and level of intelligence
a. Has attainments below expected level, but has potentials to learn within regular classroom setting given
appropriate learning reforms and adjustments
b. Has significantly low level of attainment in most areas of the curriculum despite appropriate intervention
c. May need help in all areas of the curriculum and can experience difficulties in mobility and coordination,
communication and perception, and self-help skills as well
4. Others, please specify: _____________________________________________________________________

C. Communication Difficulties:
1. Has problems understanding spoken language and reading comprehension
2. He/she stutters, stammers as he/she speaks
3. Has persistent difficulty in the social use of verbal and nonverbal communication and hinders effective
communication, social participation, social relations, academic achievement or occupational performance.
4. Others, please specify: _____________________________________________________________________

D. Autism Spectrum
1. Has persistent lack of social communication and social interaction, manifested by extreme unresponsiveness
to others
2. Manifests restrictive, highly repetitive and rigid patterns of behavior, interest or activities

E. Attention Deficit/Hyperactive Disorder

1. Has a persistent condition of inattention and/or hyperactive -impulsivity that interferes with functioning or
development

F. Physical and Motor Difficulties

1. Has a condition affecting the muscles or the nerves that control the muscles where loss of muscle strengths
is progressively manifested with the experience of frequent falls, difficulty getting up from a lying or sitting
position, trouble running and jumping
2. Has deficits in the acquisition and execution of coordinated motor skills, manifested by clumsiness and
slowness that cause interference with activities of daily living
3. Has an abnormal curvature in the spine or backbone that affects posture and movement or has sideways
curvature of the spine with manifestations of one shoulder blade that appearing more prominent or higher
than the other and uneven waist or one side of the waist higher than the other

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 4. Muscles are weak and stiff, especially under effort, which affects his/her movements, posture, balance, and
speech
5. Has a brain condition where involuntary, uncontrollable, unusual and repetitive sounds and body movements
are noticeable
6. Has repetitive, seemingly driven and apparently purposeless motor behaviors, such as hand flapping, body
rocking, head banging, self-biting or hitting.
7. Has physical limitations and difficulties as a result of an accident or disease
8. Missing Limb/s(please specify what limb) ____________________
9. Has physical incapacity since birth such as (please specify) ________________________________________
10. Incurred an injury that caused partial or full paralysis (please specify) _______________________________
11. Others, please specify: _____________________________________________________________________

G. Medical Conditions
1. Has Asthma where airways gets enlarged and narrow that produce extra mucus with the experience of
breathing difficulty, coughing, wheezing, chest tightness or pain, and shortness of breath
2. Has Diabetes where there is too much glucose in the blood with the experience of slow-healing sores, high
blood pressure, frequent infections, such as gums or skin infections and vaginal or bladder infections
3. Has allergic skin reactions, constriction of the airways and a swollen tongue or throat, that can cause
wheezing and trouble breathing, nausea, or fainting
4. Has recurrent seizures that produce temporary confusion, uncontrollable jerking movements of the arms
and legs, and/or loss of consciousness
5. Other medical condition (please specify) _______________________________________________________

H. Major Psychological Disorders

1. Has a psychological condition manifested by disturbed thought processes and having thoughts that are far
from reality, symptoms of seeing or hearing things that don't exist; having beliefs not based on reality, lack of
emotion, social withdrawal, and illogical thinking
2. He/she suffers from a mood condition characterized by profound feelings of sadness and despair, unrelenting
lack of pleasure in life, having feelings of emptiness, worthlessness or guilt and/or, having frequent thoughts
of death, suicide attempts or suicide
3. Shows extreme mood swings that include one or more episodes of overexcitement and unrealistically
optimistic state.
4. Has a condition wherein the core of disturbance is fearful behavior with manifestations of constant worrying
or obsession about small or large concerns, restlessness and feeling on edge, difficulty concentrating,
trembling, and being easily startled and it is interfering with your work, relationships, or other parts of your
life
5. Has repetitively violated the rights of others and disregarded basic guidelines of courtesy and respect to
people, property and law

I. Other significant observations, not included in the list, which may require special attention:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

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II. Diagnostic Information
Diagnosis: ______________________________________________________________________________________
Attending Professional(s): _________________________________________________________________________
Nature of Profession: _____________________________________________________________________________
Date of Assessment: ______________________________________________________________________________
Place of Assessment: _____________________________________________________________________________
Inclusive Dates of Continuing Medical/Professional Assistance: ___________________________________________
_______________________________________________________________________________________________
Interventions received: ___________________________________________________________________________
_______________________________________________________________________________________________
Assisting agency(ies): _____________________________________________________________________________
_______________________________________________________________________________________________

III. Certification from attending professional:

I have a medical certificate containing my diagnosis and treatment.
I have a certification from the attending professional that I am fit and capable to enter classes for a
regular semester.
I have no medical certificate but I will furnish the Guidance Center by ____________ ____, 20___.
If I fail to submit the required certification from my attending physician, I may ask to withdraw with permission as
the main intention is to ensure my well-being or best interest.

___________________________________________ _____________________ __________________________

Student’s Signature over Printed Name Contact Number/s: Date

GUC 05252021
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