Personal Information Form

Part One. Your Contact Information
Please fill out this basic information about who you are and how to reach you. This information will not be released to anyone other than those you'll be working with at ALT.

1.	Name (Last, First, Middle):	, ,
2.	Mailing Address:	,
3.	Daytime Phone:
4.	Evening Phone:
5.	Alternate Phone:
6.	E-mail Address:
7.	What is the best way to contact you?
8.	How did you hear about us?
9.	What do you expect from us? (Check all that apply.)	Help on passing a licensing exam Help in improving school performance Help in getting Special Accommodations for a licensing exam.      (Please specify the date you intend to take it: --- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ---- 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 .) Help in getting Special Accommodations for school Not sure Other

Part Two: Your Educational History
Please answer the following questions.

1.	Which schools did you attend or are you attending?
2.	When did you graduate, or when are you planning to graduate?	--- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ---- 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
3.	Please indicate what special accommodations you received at this school, if any. (Check all that apply.)	Extra time.     For exams? Papers? How much? Describe.      A private room. Earplugs. Breaks.     (When and how long? ) A typewriter or word processor. Other.     Please describe:
4.	What was your health like during your attendance at this school? (Check one.)	never better  pretty good  average  below average  went down a lot
5.	What college or university did you attend?
6.	When did you graduate?	--- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ---- 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
7.	What was your major?
8.	If there's anything else you'd like to let us know about your educational history, tell us here:

Part Three. Your Personal History
Please answer the following questions.

1.	Have you ever been diagnosed with a learning disability?	no  yes
2.	Date of Birth:	--- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ---- 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
3.	Place of Birth:
4.	Did you speak a language other than English for the first five years of your life?	no  yes
5.	Has anyone in your family ever been diagnosed with a learning disability?	no  yes
6.	What was your health like, growing up? Check one.	never better  pretty good  average  below average  went down a lot
7.	Are you taking any medications presently?	no  yes
8.	Have you ever had an accident where you lost consciousness?	no  yes
9.	If you answered yes to question #8, please describe how old you were, what happened, and how long you were "out of it".

10.	Generally, I have problems sleeping now.
11.	My sleeping habits have altered significantly during some point in my life.
12.	I don't feel rested when I wake up.
13.	Sugar or caffeine affects my sleep a lot.
14.	I am taking medication that affects my sleep.

Part Four. Your Learning Style

How do you think you do in the following areas?
1.	Being able to concentrate while I study.
2.	Being able to pay attention to what I'm studying.
3.	Being able to ignore distractions in my environment while I'm studying.
4.	Being able to ignore random thoughts and feelings, and sensations that may arise while I'm studying.
Please check how you feel about the following statements.
5.	The temperature in the room has to be "just right" for me to study.
6.	Air circulation in the room has to be "just right" for me to study.
7.	Repetitive thoughts often disrupt my ability to study.
8.	I'm often too anxious to study.
9.	I am only able to study in quiet environments.
10.	I am only able to study in a certain place.
11.	I am very distracted by noise.
12.	The time it takes for me to "settle down" will have a greater impact on my studying session than the actual book in front of me.
13.	I find myself with 'brain mush' after an hour or two of concentrated studying.
14.	I never seem to be able to study as hard as I know I could - or need to.
15.	I search for 'tricks' or memory devices that I feel are more helpful rather than attempting a 'general' understanding of the test material.
16.	I often find myself at the end of a textbook section without a real understanding about what was on its pages.