MIDLANDS
TECHNICAL
COLLEGE
DISABILITY SERVICES
INTAKE FORM (to be completed by student only)
Student Name:
Student ID Number: Birth Date: Primary Campus:
Address:
Student Phone: MTC Email Address:
Disability Services E-Newsletter? ¨ Yes ¨ No
What is your primary disability(ies)?
Have you ever received disability accommodations in the past? ¨ Yes ¨ No
If “Yes,” please describe where:
If “Yes,” please describe the accommodations you received:
What accommodations do you believe would be helpful to you in your studies at Midlands Technical College?
Release of Information
I authorize the Counseling Services Sta to receive information and release information to the following persons:
¨ Faculty/Sta (The sta of Counseling Services will only discuss my accommodations and/or disability-related challenges,
and will not discuss the nature of my disability with faculty/sta without prior consent.)
¨ Other:
Name and Phone Number
¨ Qualified Professional:
Name and Phone Number
My request for accommodations will be complete and reviewed only after submission of the Disability Services Intake Form,
documentation, and completion of initial interview. I will be notified of the decision regarding accommodations in writing.
I understand that I am able to complete the Counseling Services Appeal Process if I am in disagreement with a decision.
Student Signature Date
Disability Services Signature Date
Counseling Services adheres to strict standards of confidentiality and is compliant with the Health Insurance Portability and Accountability Act [HIPAA] of 1996 and the Family
Educational Rights and Privacy Act [FERPA]; facsimile transmittals and records are stored in a secure location and reviewed only by authorized personnel.
Counseling & Career Services Staf Only:
Intake Form Received Date: Received By: Review Date:
Documentation Received Date: Received By: Academic Program:
Training Program: Requesting Semester:
midlandstech.edu
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PO Box 2408
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Columbia, SC 29202
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airport 803.822.3505
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beltline 803.738.7636
SD-19-5653-05-19
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