STUDENT INTAKE FORM
The Campus Access Services (CAS) office coordinates reasonable accommodations and/or
services for students who provide appropriate documentation of a disability and request
accommodations in a timely manner in accordance with established university policies and
procedures. The information below is requested to enable us to mobilize appropriate university
resources to provide reasonable accommodations to qualified students with disabilities. The
information requested on this form, in accordance with the Family Education Rights Privacy Act,
is a part of the student’s academic record but is maintained in the CAS office apart from the
student’s formal academic records.
Student’s Name
Major
Street Address
Cell phone
City
Age
State
Date of Birth
Category(ies) Of Disability:
Zip
Email Address
(please check all that apply, list specific disorder where requested)
Specific Learning Disability
ADD/ADHD
Acquired Brain Injury
Speech Impaired
Deaf/Hard of Hearing
Blind/Visually Impaired
Non-Ambulatory
Semi-Ambulatory
Autism Spectrum Disorder
Recovered Substance Abuse
Psychiatric/Emotional (diagnosis):
Military Related Condition (describe):
Chronic Health Related (diagnosis):
Other (diagnosis/describe):
Please describe the impact of your disability/medical condition in an academic setting:
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Affiliations Off-Campus:
Client of the Bureau of Rehabilitation Services?
Yes
No
Client of the Board of Education & Services for the Blind?
Yes
No
Client of the Veterans Administration Hospital?
Yes
No
Client of the Veterans Center?
Yes
No
Name of Counselor (at any of the above):
Other Professionals with whom you meet (please list below):
Do you need an accessible room in Campus Housing?
Describe Specific Modifications:
Yes
No
If yes, please complete the “Request for Modification to Housing and/or Dining Options” packet
and return by deadlines listed on the Campus Access Services webpage.
Go to:
http://www.newhaven.edu/CampusAccess
High School History:
High School Attended:
High School GPA:
SAT Reading:
SAT Math:
ACT Score:
SAT Writing:
Medical/Mental Health History:
1. Have you ever been hospitalized or treated for a psychiatric/emotional illness?
(If Yes, Please Describe)
No
Yes
2. Are you currently/have you in the past received individual therapy/counseling?
3. Do you currently utilize or will you need the services of a Personal Care Assistant/CNA or
Nurse in order to attend college?
If Yes, approximate number of Hours per Day:
Does this include overnight care?
4. Please list any side effects of your current medications that may impact your performance
in the academic setting.
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5. Please list any additional information that you think we should know that would help us to
better provide appropriate services and/or reasonable accommodations?
6. What accommodations/services have you used in the past?
7. Which of your previously used accommodations/services did you find most useful, and why?
Accommodation/Service
Why it helped
8. What accommodations would you ideally like to use at University of New Haven, and why?
Accommodation/Service
Functional Limitation
Source(s) of Documentation for Your Disability/Medical Condition
(Physician, School Psychologist, Agency):
Name
Title
Address
Phone (
City
)
Fax Number (
Name
Title
Address
City
Phone (
)
Fax Number (
State
Zip
State
Zip
)
)
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*You may use a Release to Obtain Confidential Information form to facilitate your
request to have documentation submitted to the Campus Access Services office of the
University of New Haven. This form is available on our website.
Documentation of a learning disability should include comprehensive, current test results
(within the past three (3) to five (5) years).
Documentation of a psychiatric/emotional disorder should be current (within the past
three (3) to six (6) months). You may download a CAS Verification of Psychiatric Disorders form
from our website and submit it to your provider for completion to facilitate documentation of
your disability.
Documentation of ADD/ADHD should be current (within the past three (3) to five(5) years).
You may download a CAS Verification of ADD/ADHD form from our website and submit it to
your provider for completion to facilitate documentation your disability.
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Request for Reasonable Accommodations and/or Services:
By my signature below, I am requesting reasonable accommodations for my disability, chronic
health related condition or military active duty related condition. I understand that in order to
receive reasonable accommodations, I must submit documentation of my disability, chronic
health-related condition or military active duty related condition to the Campus Access Services
office, be found eligible for services/accommodations, and must request reasonable
accommodations in a timely manner in accordance with the university’s established policies and
procedures.
I understand that Campus Access Services offers enhanced services (such as tutoring,
executive functioning support, mentoring, monitoring, etc.) that are beyond any reasonable
accommodations I may be found eligible for, and though these may be offered for my benefit, I
understand that they are not required under the ADAAA nor Section 504 of the Rehabilitation
Act.
I understand the staff at Campus Access Services may contact me to share information
regarding the office or myself via the phone number I have provided on page one of this form
and also via the email address provided by the University of New Haven.
I have
, I will
, request(ed) documentation be sent to Campus Access Services by the
appropriate professional(s) listed on page three of this form.
*Date requested:
Student’s Signature
Date
Witness Signature
Date
For Office Use Only (To be completed ONLY by a CAS staff member):
Date Received
/
/
Staff Initials _________________
Student Status:
DOCUMENTATION ___ Complete ___/___/___ Date Received
___ Partial
___ Referred for Testing
___ Temporary Accommodations Provided
Undergraduate Full-Time Day
Undergraduate Eve/Part-Time
Graduate
Semester of Enrollment at UNH: Fall _______ Spring _______ Summer _______
Semester Registered with CAS:
Fall _______ Intersession _________ Spring _______ Summer _______
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