Disability Services Intake Form

Disability Services Intake Form — Form Fields

This education template includes 6 fields. Collect information from students seeking support from the disability services office for the first time. Helps disability services advisors understand each student's needs and available documentation. Enables timely arrangement of appropriate academic accommodations. Free to customize and use on ZenBuild.

• Student Full Name (text, required)
• Student Email (email, required)
• Enrollment Level (dropdown selection, required) — options: Undergraduate, Graduate, Certificate program
• Type of Disability (dropdown selection, required) — options: Learning disability, ADHD, Physical / mobility, Visual impairment, Hearing impairment, Mental health condition, Chronic illness, Other
• Have you received disability services at a previous institution? (multiple choice, required) — options: Yes, No
• Describe how your disability affects your learning (long text, required)