Form Wtw 19 - Learning Needs Screening

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
LEARNING NEEDS SCREENING
CLIENT COPY
I am going to ask you questions about your school experiences and your health. Your
answers will help me figure out what, if anything, is getting in your way of training and
working. Your answers will also help me develop your welfare-to-work plan and help
me figure out what services you may need to be successfully employed. It is very
important that you answer these questions so that I can determine the right kind of
welfare-to-work activities for you, and to get you the help and services you may need
to succeed. These questions are not intended to determine the existence of a learning
disability. They are only the first step in the evaluation process.
Please keep in mind that most people with learning disabilities are intelligent and many
are gifted. Individuals with a learning disability may have difficulty with the following:
• Reading
• Math
• Listening
• Organizing things
• Understanding directions
• Getting along with others
• Writing
• Expressing ideas out loud
• Spelling
• Paying attention
Individuals with a learning disability can be taught to use their strengths and find ways
to make it easier to learn and be more successful at school and on the job. I can help
individuals get the appropriate welfare-to-work activities, including accommodations
once a learning disability is identified.
Please keep in mind this screening is a very simple and short test. It will help you decide
if you would like a referral to a learning disability specialist for an evaluation to find out
if a learning disability exists. The areas that will be tested at evaluation are the following:
• Natural talents and abilities
• Ability to follow verbal and written information
• Achievement
• Job and Career interests
The specialist can help identify strengths and weaknesses so that we can make referrals
to the appropriate services and accommodations for you. Please remember that you
have the right to file for a fair hearing if you disagree with a county action including
actions related to learning disabilities.
If you are Limited-English proficient and a Learning Needs Screening is not available
in your primary language, you have the right to request a referral directly for a learning
disabilities evaluation.
WTW 19 (11/15) COVERSHEET - REQUIRED FORM - NO SUBSTITUTES PERMITTED
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