DISABILITY SUPPORT SERVICES (DSS)
INTAKE/HISTORY
Name: _________________________________ Birth Date: _____________________________
Student ID#: _______________________ Email: ______________________________________
Address: _______________________________________________________________________
Home Phone: ________________ Cell Phone: ________________ Today’s Date: ____________
Please answer the following questions:
Please list all schools you have attended in the past:
What is the highest grade you completed?
Did you attend special education classes? If yes, in what subjects?
Have you ever had a serious illness? What was the nature of the illness?
Have you ever had a serious accident? Describe it.
Have you ever had problems with alcohol or drugs? If yes, did you receive treatment?
Have you ever received treatment or counseling for personal or emotional problems?
