Student Intake Form

Please be advised that in addition to the Student Intake Form you must submit to Disability Services documentation of your disability from a qualified or licensed professional. Documentation should be scanned to your Box folder. Please share your documentation in Box with our Intake Coordinator at notify@admin.umass.edu. This is the fastest and most secure way to send along your documentation. You may also scan it to an app such as Genius Scan and email it to us. We can accept scans, but not pictures of letters. You may also fax it to us at 413-577-0122 but due to remote access, we can only access faxes twice a week.

Once we have received your documentation and intake form, we will confirm email receipt via your UMass email address and encourage you to schedule an appointment with a Consumer Manager(CM). You may call the main office at 413-545-0892 to schedule an appointment or email the CM directly to schedule a first appointment by utilizing the staff contact page. Please be sure to clarify your full name and a phone number or UMass email where you can be reached. Remote appointments will occur on Zoom or by phone.

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 your email account regularly.
Please select below if you require any of the following accommodations, as they require collaboration and additional time to put in place. This is not a list of all accommodations.
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.