Accessibility Services Department Intake Form
Name:
UV ID:
Date of Birth:
Phone:
Address:
Major:
City:
State:
Student Email:
Presenting Diagnosis
Please check the concerns you have as a student:
___Reading
___Physical
___Emotional Concerns
___Writing
___Hearing
___Medical
___Math
___Vision
___Memory
___TBI/Head Injury
___Seizures
___ADHD
Date of Injury_________________
1. Please describe your disability:
_______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2. How can ASD help you?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
9/15/14