Intake Form

Please Print this intake form, fill it out, sign it and bring it with you for your first appointment with a disability specialist.

 

 

STUDENT DISABILITY SERVICES

STUDENT INTAKE FORM

Personal Data

(Name) First:____________________________ Middle:___________ Last: ______________________

WSU # ID:________________________________________Today’s Date: _____________

Address: __________________________________________

City:___________________________________ State:______ Zip Code: __________________

Birth date: ___________________________

Home Phone: (     )_________________ Cell Phone: (    ) __________________

Work Phone: (    ) _________________

Student’s Wayne State e-mail address: ________________________________

What’s the best way to reach you? (Check all that apply.)

Cell ____ Home ____ Work ____ e-mail ____ Gender/ check one: [  ] Male [  ] Female

Ethnicity:

If your ethnic origin is among the following, please indicate by placing a circle around the correct title:

White/Caucasian (non-Hispanic) Black/African American (non-Hispanic) Hispanic/Latino

American Indian/Alaskan Native Asian Hawaiian/Pacific Islander Arab American

Multi-racial (specify): _________________________________

Other (specify): ______________________________________

How did you find out about SDS?

Faculty [  ] Staff [  ] Community [  ] Internet [  ] Agency [  ] Other [  ]

Are you registered with other community services? (Ex: MRS or Commission for the Blind)

[  ] YES [  ] NO

If yes: Agency Name:_______________________________________________________________

Case Worker: __________________________________________________

Phone: (   )_____________________________

 

Academic Data

Major: ______________________________________Transfer Student from: ____________________

Current Academic Status: (please circle) Fr/ Soph/ Jr/ Sr/ Grad/Other

Current GPA: ___________Credit Hours this Term: ___________

Short term Academic Goals: (please circle) BA/BS, MA/MS/MSW/M.ED, PH.D/JD/DR.

Accommodation History

Previous Educational Accommodations: __________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________ 

Please list any previous accommodations issued and/or any accommodations you are requesting:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

 

I understand that the accommodations for which I am requesting must be supported by proper documentation from a qualified individual according to the SDS documentation guidelines.

Student Signature:________________________________________________________Date:______________