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Confidential Application Form
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Form Completed by:
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Relationship to applicant:
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Date Completed:
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Semester and year for
which student is applying:
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How did you hear about
AHEADD?:
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Please complete this form to the best of your ability.
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1. Basic Identification
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Student’s Name:
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Gender:
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Birthdate:
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Email:
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Cell Phone:
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Parent/Guardian:
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Home Phone:
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# where parent can be
reached during day:
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Parent email:
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Mailing Address:
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2. Family History
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Father’s Name:
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Age:
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Education:
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Occupation:
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Mother’s Name:
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Age:
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Education:
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Occupation:
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Marital Status
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Unmarried
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Married
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Separated
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Divorced
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Other immediate family
members.
(name/age/relationship)
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Are there any family
members, including those
listed above, who have
experienced similar
difficulties as the
applicant? If so, please
list person, relationship,
and type of difficulty.
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No
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Is the student adopted?
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Yes
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If so, at what age?
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3. Higher Education Application Information
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Has the student submitted
applications for higher education?
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No
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Yes
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Has the student been accepted for
admission into higher education?
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No
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Pending
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Yes
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Has the student enrolled in higher
education?
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No
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Pending
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Yes
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If Yes, into which school?
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4. Diagnostic History
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This information is beneficial in terms of developing suitable programming for this student.
Please include initial evaluations and most recent evaluation, preferably done within the last six
months. Records may include psycho-educational evaluations, diagnostic statements,
developmental and social histories, and specific reporting of standard scores and scaled
scores of instruments used to assess the student. Please mail this information to AHEADD,
3945 Forbes Avenue #470, PITTSBURGH, PA 15213.
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5. Educational History
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Preferred subjects and
academic strengths:
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Subjects of greatest
challenge:
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Describe when any
academic difficulties
occurred, and what type
of help or
accommodations were
utilized. How have
difficulties and
accommodations
changed over time? What
service(s) is the
student currently
receiving?
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6. Developmental History
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Is the student currently
taking any medications?
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No
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Yes
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If yes, please list:
(medication/dosage/reason)
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Describe any significant
medical and/or mental
health issues.
(i.e. hospitalizations,
diagnoses, etc.)
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Does the student have a
history of physically or verbally
aggressive behavior?
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No
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Yes
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If yes, please describe:
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Please provide the name,
email address and
telephone number of two
professionals that we can
contact regarding the
applicant (teacher, guidance
counselor, coach, etc):
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7. Applicant's Statement
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Applicant, you should complete this section in an honest, thorough, and thoughtful manner. Please
use your own words.
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Please describe your
favorite hobbies and
interests.
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Describe the things you
find most difficult to do
when interacting with
other people.
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What are your biggest
academic challenges?
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What field of study interests
you?
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What could AHEADD do to
help you?
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