Learning Differences Form

Which statement describes your student?

New student to UHC

Returning student to UHC but new to the Learning Differences Program

Returning student to UHC and re-enrolling in the Learning Differences Program

Learning Differences Questions

A separate form must be completed for each student. The information shared on this form will be used strictly for communication between the teaching parent, teachers and directors to help meet the needs of the student.

I understand that providing a student with accomodations requires additional support from teachers and administration. Therefore, a yearly fee will be charged to my account in the amount of: $85/Elementary; $150/Middle; and/or $200/High School. Accomodations will only be provided to students enrolled in the LD program.

I Agree

UHC Campus Student Will Attend

GVL Hampton Heights (K3-5th Grade)

GVL Grace Church (6th-12th Grade)

SPT Church at the Mill (K3-High School)

Student will be in

Middle School

High School

Parent Name

First Last

Parent Phone

Parent Email

Student Name

First Last

Student Grade

Testing Information: Please check all that apply to your student.

Formal testing has not been completed. I am not sure if my student needs special accommodations, and I would like to set up a 30 minute consultation meeting.

No formal testing has been completed, but testing is currently underway. (This could include a physical disability that affects the student’s learning.)

Formal testing has been completed. I am able to provide the report to UHC upon request.

Please explain where you are in the testing process.

Please upload evaluation results.

Drop files here or

Max. file size: 50 MB.

Testing/Accommodation Information- Please check any that apply to your student:

I have updated testing results to share.

I would like to discuss adjusting my child’s accommodations.

Please upload any updated evaluation results.

Drop files here or

Max. file size: 50 MB.

Some changes I would like to recommend are:

Please describe your child's learning challenges.

For example: “She can explain answers verbally, but is unable to write down complex ideas in a way that makes sense.” or "Due to his processing disorder, he should not be asked to read out loud in front of others and will need extra time to read passages on tests."

What classroom accomodations do you feel will benefit your child at UHC? Please understand that our heart is to provide a successful learning environment for all students; however, we are not legally required and may not be able to meet all needed accomodations.

For example: "Student will not be able to take written tests in a classroom environment. All tests will need to be read to the student." or "Student will need to have her laptop to take notes." or "Student will need to sit close to the board.”

Is there anything else about your student that would be helpful for us to know regarding their ability to meet expectations in the classroom?

Mental Health Questions

Information you share is confidential and used for planning purposes and assessment of student needs for placement. We may require a parent and student interview with the LD Administrator and grade level director to better determine if UHC is the most appropriate placement.

Mental Health Crisis Policy: If a student requires more than 2 major crisis interventions (such as disturbing the teaching and learning of others, refusal to obey, and harm to self and others) during the school hours with one of our staff, the parent must come in for a meeting that will lead to one of several outcomes. A) The family may withdraw their student with prorated tuition because we cannot and will not manage such intense situations regularly. B) The parent must agree to attend class with their student and stay on campus to intervene as needed, or provide a shadow for the student. If the behavior is not improved with the parent/shadow, then the student will be dismissed from UHC with prorated tuition.

I Understand and agree to adhere to the Mental Health Crisis Policy

Does your child experience anxiety over schoolwork or relationships with peers? Please rate the level between 1 (small amount of anxiety occasionally) and 5 (extreme anxiety that inhibits participation in the classroom; panic attacks)

Has your child ever had a desire to hurt themselves or others?

Does your child have a history of anxiety or depression?

Is your child currently on any medication for anxiety or depression? If not, has your child been on medication for anxiety or depression in the past?

Is your child currently in counseling or been in counseling in the last 2 years?

Does your child have panic attacks or other medical concerns that affect their performance in the classroom?

Please share what classroom experiences your child has had in the past.

Examples: resource class, self-contained class, regular education class, homeschool co-op classes, etc

Does your child receive any support services such as speech, physical therapy, occupational therapy, or behavioral therapy? If so, please share what type of support and how long your student has been receiving it.

Is your student able to contribute to class discussions and participate in active learning environments appropriately for their age?

Does your child struggle with transitions or changes to routine?

I understand that As a member of UHC and the LD program, my child’s teachers will have full knowledge of my child’s learning challenges and disability and/or any medical condition that is relevant to the learning of my child in order to better serve my child.(Required)

I agree

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Learning Differences Questions

Mental Health Questions

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