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?
Yes
No
6.
Type of Disability:
Learning
Attention Deficit/Hyperactivity Disorder (ADHD or ADD)
Physical
Medical
Psychiatric/Mental Health
Other (please specify)
7.
Previous Disability Support:
IEP
504
Doctor/Therapist Supervision
Other (please specify)
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?
Yes
No
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?
Housing
Meal
Academic Support
ESA
Electronic Books
Testing Support
Other (please specify)
14.
Please provide any additional information you would like to share that would help us serve you better:
