Disability Services Intake Form Question Title * 1. Name: Question Title * 2. Email Address: Question Title * 3. What is your phone number? Question Title * 4. What is your program of study? Question Title * 5. Are you currently enrolled in classes? Yes No Question Title * 6. Type of Disability: Learning Attention Deficit/Hyperactivity Disorder (ADHD or ADD) Physical Medical Psychiatric/Mental Health Other (please specify) Question Title * 7. Previous Disability Support: IEP 504 Doctor/Therapist Supervision Other (please specify) Question Title * 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): Question Title * 9. Please list your official diagnosis(es) or medical/mental health condition: Question Title * 10. Are you able to provide documentation from a health care or mental health provider? Yes No Question Title * 11. Briefly describe your major symptoms and/or primary effects of your condition(s). How long do symptoms last and how severe are they? Question Title * 12. Please describe how your condition impacts your educational experience and major life experience: Question Title * 13. What type of accommodation are you requesting? Housing Meal Academic Support ESA Electronic Books Testing Support Other (please specify) Question Title * 14. Please provide any additional information you would like to share that would help us serve you better: Done
