Getting Started Form

Questions

1.  

   What brings you to Disability Support Services?

   I am looking for information and want to explore my options.

   I am looking for accommodations.

   Other (Specify Below)

   Additional Note or Comment
2.  

   Have you used accommodations in the past?

   No

   Yes, in K-12 through an IEP or 504 Plan

   Yes, in a college or university setting

   Yes, through employment

   Other (Specify Below)

   Additional Note or Comment
3.  

   Please indicate the type and nature of disability you experience.

   ADHD/ADD

   Autism Spectrum Disorder

   Developmental Disability

   Dexterity Limitations

   Hearing Impacts

   Learning Disability

   Mental Health Disability

   Mobility Limitations

   Medical or Health Condition

   Speech/Language Impacts

   Visual Impacts

   Temporary Disability Condition

   Other (Specify Below)

   Additional Note or Comment
4.  

   Functional Limitations- I have difficulty with:

   Seeing: printed materials, overheads, chalk/whiteboard, program access, other

   Hearing: lectures, group discussions, speaking, other

   Learning: taking notes, In-class assignments, other

   Understanding: textbooks, lectures, discussions, handouts, graphs/charts, other

   Testing: completing on time, easily distracted, other

   Physical Activities: sitting, stairs, manipulating objects, manual task, other

   Participation: attending class regularly, focus/concentration, groups, other

   Communicating: with instructor, other

   Emotional: managing behaviors and/or emotional self-regulation during class, self-care, other

   Other (Specify Below)

   Additional Note or Comment
5.  

   Have you completed any of the Clark DSS steps previously, such as providing documentation or completing an intake appointment? (Note: If you answer no, we will not check our past files and we will consider you a new student with DSS.)

   Yes

   No

   I am not sure

   Additional Note or Comment