Disability Intake Questionnaire

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You should complete this form before you visit with the Director for Disability Services.

Email
This field is for validation purposes and should be left unchanged.
General Information
Today's Date*
Month
Day
Year
Semester of Entry*
- Fall
- Spring
- Summer
Select the semester you will begin classes at 51��.
Entry Date*
Month
Day
Year

Enter the date you will begin classes at 51��.
Name*
First Last

Enter your full name.
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Student ID*
Birthdate*
Month
Day
Year

Enter your date of birth.
Phone*
Enter a phone number where you can be reached.
Email*

Enter your email address.
Disability Information
In this section you will tell us about your disability.
1. What diagnosed disability are you seeking accommodations?*
- Attention Deficit Hyperactivity Disorder (ADHD)
- Autism Spectrum Disorder
- Blind / Visual Impairment
- Brain Injury
- Chronic Illness
- Communication Disorder (e.g. language disorder, speech sound disorder, stuttering)
- Deaf / Hard of Hearing (HOH)
- Intellectual Disability
- Learning Disability (LD)
- Mental Health Impairment
- Mobility Impairment
- Other
You can press the space bar to mark a checkbox. Check all that apply.
Please explain chronic illness*
Please specify Mental Health Impairment*
- Anxiety disorders
- Bipolar and related disorders
- Depressive disorders
- Disruptive, impulse-control, and conduct disorders
- Dissociative disorders
- Obsessive-compulsive and related disorders
- Personality disorders
- Schizophrenia spectrum or other psychotic disorders
- Sleep-wake disorders
- Trauma- and stressor-related disorders (PTSD, Adjustment, reactive attachment, etc.)
- Other
Other Mental Health Impairment*
Other disability not listed: Please specify.*
If your disability was not listed above, you can list it here.
2. When was this disability first identified or diagnosed?*
3. Are you taking any medications that might affect your attendance or performance at college?*
- Yes
- No
You can use the up and down arrow keys to select an option.
3 a. You selected yes. How may these medications affect your physical, sensory, perceptual, behavioral or cognitive performance?*
4. Please provide a descriptive narrative of your disability(ies) in your own words and explain how it/they affect(s) you in an academic setting (and living situation if staying in the 51�� residence halls)*
5. How does your condition impact you in classes regarding the following: Listening, notetaking, speaking, writing, keyboarding, sitting, attendance?*
6. How does your condition impact you in evaluations regarding the following: tests, papers, oral reports, group projects?*
7. How does your condition impact you when doing out of class assignments in the following areas: reading, writing, calculating, keyboarding, library work?*
8. How does your condition impact you when there are time constraints in the following area: timed tests, deadlines, class schedule:*
9. How does your condition impact your mobility in the following areas: manipulating objects, transportation & getting around, other mobility effects?*
10. How does your condition impact you in other areas: sleep, interacting with others?*
11. Have you received accommodations for this disability in the past?*
- Yes
- No
11 a. You selected yes. What auxiliary aids, assistive devices, support services, and accommodations have you used or are youcurrently using that are effective in lessening the impact of the disability?*
Accommodation Approval Agreement
I understand that completing this form is only the initial step in the accommodation process. Once I am registered with 51�� Disability Services, I will need to meet with a Disability Services Counselor each semester to request accommodations and complete Accommodation Letters for Faculty.

I also understand that I am my own advocate. It is my responsibility to request accommodations and to notify instructors of my need for accommodations. It is also my responsibility to report any concerns I may have regarding accommodations to the Disability Services Office.

Documentation of your disability must be provided to the Disability Services office before accommodations will be provided. I realize that I may need additional documentation upon transferring to another educational institution. It is my responsibility to consult with the transfer institution regarding their documentation requirements.
Accommodation Approval Agreement*
- I have read and agree to the "Accommodation Approval Agreement"
Disability Services in College Statement
51�� (51��) is committed to providing reasonable accommodations to qualified students with disabilities. These accommodations are provided to assist students with disabilities in accessing education at 51��. Working in partnership with the student, the Disability Services Counselor will develop an individual plan for services that will include accommodations in testing and instruction. A student with disabilities must submit documentation to verify presence of a disability and request services each semester. Please note that program requirements will not be altered and standards will not be lowered.
Disability Services in College Statement*
- I have read and fully understand the "Disability Services in College Statement".
Statement of Confidentiality
51�� Disability Services is committed to ensuring that all information and communication pertaining to a student's disability is maintained as confidential as required or permitted by law.

The following guidelines about the treatment of such information have been adopted by 51�� Disability Services. These guidelines incorporate relevant state and federal regulations.

1. No one will have immediate access to student files in 51�� Disability Services except appropriate staff of 51�� Disability Services. Any information regarding a disability is considered confidential and will be shared only with others within the college who have a legitimate educational interest.

2. This information is protected by the Family Educational Rights and Privacy Act (FERPA).

3. Sensitive information in 51�� Disability Services student files will not be released except in accordance with federal and state laws.

4. A student's file may be released pursuant to a court order or subpoena.

5. If a student wishes to have information about his/her disability shared with others outside the college, the student must provide written authorization to the Counselor for 51�� Disability Services to release the information. Before giving such authorization, the student should understand the purpose of the release and to whom the information is being released. The student should also understand that there may be occasions when the Counselor for 51�� Disability Services will share information regarding a student's disability at his/her discretion if circumstances necessitate the sharing of information and the Counselor has determined that there is an appropriate legitimate education interest involved.

6. A student has the right to review his/her own 51�� Disability Services file with reasonable notification.

I have been informed of the policy regarding confidentiality and the release of information from my 51�� Disability Services file. I understand that 51�� Disability Services may release information from my file to be used in a confidential manner with appropriate college faculty and officials who have a legitimate educational interest while I am a student at 51��.
Statement of Confidentiality*
- I have read the "Statement of Confidentiality" and fully understand it's terms and conditions.

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Disability Intake Questionnaire

General Information

Disability Information

Accommodation Approval Agreement

Disability Services in College Statement

Statement of Confidentiality

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