Student Intake Form

Personal Information
Permanent Mailing Address
Contact Information
Disability services will use your campus email address as the primary method of communicating with you regarding appointments and your accommodations. Please check our email account regularly.
Additional Information
Please check all the boxes that accurately describe you. Disability Services will use this information to support you with identifying campus resources as needed, as well as for anonymous statistical purposes
Privacy Agreement
By checking the box below, you give Disability Services permissions to share relevant information on a need-to-know basis with University administrators, faculty, health or counseling staff, and /or emergency personnel; to release relevant information to agencies that provide external support; and to request information about you from other campus offices. Please list any restrictions to this authorization below your approval.