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The Clinical Center for the Study of Development & Learning UNC Center For Development & Learning

Young Adult Contact Form
(Please fill this form out using Internet Explorer 6.0 or later)

Click submit after completing this form online or print it and mail or fax it to:
Center for Development and Learning
University of North Carolina at Chapel Hill
CB# 7255
Chapel Hill, NC 27599-7255
Fax: 919-966-2230

Applicant Information
Applicant's Full Name   
(First, Middle, Last)
Gender
Nickname
Date of Birth
MM/DD/YY		 Age
Street Address
City, State Zip ,
County
Home Phone
(xxx) xxx-xxxx		 Work Phone
(xxx) xxx-xxxx
Cell Phone
(xxx) xxx-xxxx		 Email
Applicant Lives With Parent/Guardian(s) Name(s)

Primary Contact Person
Full Name Relationship to Applicant
Street Address
City, State Zip ,
County
Home Phone
(xxx) xxx-xxxx		 Work Phone
(xxx) xxx-xxxx
Cell Phone
(xxx) xxx-xxxx		 Email

Referral Source
Person Completing this Form Relationship to Applicant
Referred to CDL by Relationship to Applicant

Primary Concerns
What are your primary concerns Please be as specific as possible.
1
2
3

High School/College Experience
Has the applicant graduated from high school?
If yes, please describe type of diploma, school and date of graduation.
Did the applicant need any special assistance in high school?
If yes, please describe.
Is the applicant currently employed?
Please list employment history starting with the most recent position:
Company Position Duties Dates
What are the applicant's hobbies and interests?
Is the applicant currently enrolled in a college, university or technical school?
Has this individual attended a college or university in the past?
If yes, please describe when and where.

Diagnoses/Assessments
Has the applicant been assessed previously for school performance, learning, behavioral, developmental and/or social-emotional problems?
If yes, type of testing and when?
Diagnosis and/or IQ?
Is the applicant currently receiving any services or therapies?
If yes, please describe.
Has this individual been seen at UNC Hospitals or any UNC Clinics before?
If yes, please provide his or her UNCH medical record #:

Clinical Evaluations
The Young Adult Program offers evaluations for young adults from age 18-30 that have graduated from high school and are transitioning into the world of work and/or college. The focus of the evaluation is to provide young adults with a life plan that integrates their strengths, weakness, affinities, neuropsychological profile, and job values and interests. The cost for this full day evaluation is $1,950. We do not accept insurance for this clinic; however, you may file for insurance reimbursement on your own. Payment will be expected at the time of service.

Please Note: This evaluation will not produce standardized test scores to use for qualification of disability services. However, we can also provide that service. Please indicate in the primary concerns section of this form if you are interested in standardized testing to qualify for disability services in addition to our Young Adult Program.

I have read and understand the above information:
Name Date