Disability Services Intake Form

Student and Disability Information

Student Name*

First Last

Student ID#*

Which disabilities create barriers in academic and nonacademic activities*

Academic Strengths*

Academic Challenges*

Nonacademic Strengths*

Nonacademic Challenges*

In which way(s) do you best learn?*

Check all that apply

What's the best learning environment for you?*

Check all that apply

Which of the following study skills would like to learn more about?*

At what time of the day do you tend to be the most focused and productive?*

Which of the following activities do you find challenging?*

Check all that apply

Signature*

I verify that I have answered all questions accurately and to the best of my ability. I agree that I am the person whose name appears on this form.

This information is confidential and will be maintained within your file at Faulkner University’s Disability Services Office.

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