Disability Services Intake Form

1.Name:
2.Email Address:
3.What is your phone number?
4.What is your program of study?
5.Are you currently enrolled in classes?
6.Type of Disability:
7.Previous Disability Support:
8.Please describe the services/academic accommodations you received in high school or for standardized testing (If a Grad student, please list your accommodations for your undergraduate experience):
9.Please list your official diagnosis(es) or medical/mental health condition:
10.Are you able to provide documentation from a health care or mental health provider?
11.Briefly describe your major symptoms and/or primary effects of your condition(s). How long do symptoms last and how severe are they?
12.Please describe how your condition impacts your educational experience and major life experience:
13.What type of accommodation are you requesting?
14.Please provide any additional information you would like to share that would help us serve you better: