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Self- Report Intake Form
This self-report/intake form and your supporting documentation must be received by the Department of Special Services/Project Assist in order to start receiving accommodations. Supporting documentation includes but is not limited to: Professional learning, cognitive, psychological, psychiatric, and/or medical evaluations/reports, Medical Professional letter typed on letterhead. Please see Documentation of Disability requirements and alternative medical professional forms on our website for further information.
Last Name *
Your answer
First Name *
Your answer
College Student ID# *
Your answer
Today's date *
Mailing address *
Your answer
High School graduation year/GED and name of HS *
Your answer
Phone number *
Your answer
College email *
Your answer
Program of Study (Major)
Your answer
How did you find out about this office? Did someone refer you?
Your answer
Please list the condition in which you are seeking accommodations, assistance, and/or supports. *
Your answer
Have you used accommodations and/or supports before? If yes, list/explain what you used and how each was helpful to you. *
Your answer
Please rate yourself in regards to the following activities based on a college classroom. *
no difficulty to little difficulty
Difficult- I may need supports
Understanding what I Read
Writing an Essay
Learning at a college pace/classroom
Completing assignments
Time management
Note taking
Taking tests
Study Skills
Class Presentations
Learning a Foreign language
Asking for help
Identifying a major
Peer relationships
Please list any other difficulties or concerns that were not listed in chart. If none, write N/A. *
Your answer
What do you consider to be your greatest strengths in a classroom setting? *
Your answer
Do you have medical documentation, professional evaluations, and/or medical professional letter that details your condition(s) in which you are seeking accommodations? Documentation should clearly state your diagnosis, the resulting functional limitations, and recommendations. *
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