Online Application

Please fill out the following application. Once you click submit, you will be taken to a secure
credit card processing page where you will be able to pay the application fee using any major
credit card via Google Checkout or Paypal.
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Confidential Application Form
Form Completed by:
Relationship to applicant:
Date Completed:
Semester and year for
which student is applying:
Please complete this form to the best of your ability.  
1. Basic Identification
Student’s Name:
Gender:
Birthdate:
Email:
Cell Phone:
Parent/Guardian:
Home Phone:
# where parent can be
reached during day:
Parent email:
Mailing Address:
2. Higher Education Application Information
Has the student submitted
applications for higher education?
No
Yes
Has the student been accepted for
admission into higher education?
No
 Pending
Yes
Has the student enrolled in higher
education?
No
 Pending
Yes
If Yes, into which school?
3. Diagnostic History
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.
4. Educational History
Preferred subjects and
academic strengths:
Subjects of greatest
challenge:
Describe when an
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?
4. Family History
Father’s Name:
Age:
Education:
Occupation:
Mother’s Name:
Age:
Education:
Occupation:
Marital Status
Unmarried
 Married
Separated
Divorced
Other immediate family
members.

(name/age/relationship)
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.
No
Is the student adopted?
Yes
If so, at what age?
6. Developmental History
Is the student currently
taking any medications?
No
Yes
If yes, please list:

(medication/dosage/reason)
Describe any significant
medical and/or mental
health issues.
(i.e. hospitalizations,
diagnoses, etc.)
Does the student have a
history of physically or verbally
aggressive behavior?
No
Yes
If yes, please describe:
7. Applicant's Statement
Applicant, you should complete this section in an honest, thorough, and thoughtful manner. Please
use your own words.
Please describe your
favorite hobbies and
interests.
Describe the things you
find most difficult to do
when interacting with
other people.
What are your biggest
academic challenges?
What field of study interests
you?
What could AHEADD do to
help you?
When you click submit application, you will be taken to our payment page
where a $50 application fee can be paid for with any major credit card.
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AHEADD - 3945 Forbes Avenue #470 Pittsburgh, PA 15213 - (412) 848 - 9355
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