Fillable Interactive Intake Application (Las Positas College)

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Interactive Intake Application (Las Positas College)

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The Interactive Intake Application (Las Positas College) form is 4 pages long and contains:

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44 check-boxes
56 other fields

Country of origin: US
File type: PDF

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

DisabledStudentPrograms&Services

(L):DSPSData|NewForms|FinalDrafts6.4.19

3000CampusHillDrive|Room1615,Livermore,CA94551



INTERACTIVEINTAKEAPPLICATION



StudentName___________________________W#____________________________



Term/Year_________________________DateofBirth________________________



PleasecompletethisintakeapplicationandsubmitittotheDisabilityResourceCenter(in

Building1600,Room1615)alongwithdocumentationofyourdisabilitypriortoyour

scheduledappointmentwithaDisabledStudentProgramandServices(DSPS)Counselor.

Somesourcesofdocumentationthatarecommonlyusedtoverifyadisabilityinclude,but

arenotlimitedtothefollowing:

 AppropriateagenciessuchasK‐12schooldistricts,othercolleges/universities,

RegionalCenters,Veteran’sAffairs,socialand/orgovernmentalserviceagencies,and

 Certifiedorlicensedprofessionals suchasMedicalDoctors,Clinical

Psychologists,

Therapists,Ophthalmologists,Audiologists,andSpeechTherapists.



Doyourbesttobeasdetailedaspossiblewhencompletingthisapplicat ion.Anyadditional

informationthatyouwouldliketoaddiswelcome. Youwillreviewtheformsandthe

applicationatyourintakeappointment,soyoumayaskquestionsatthattimeaboutitems

youdidnotunderstand.Your

responses,thedocumentationofdisabilitythatyouprovide,

andtheintakeappointmentwiththeDSPSCounselorwillbeusedtodetermineeligibilityfor 

services.InformationyousharewiththeDSPSisconfidential,protectedbytheFamily

EducationalRightsandPrivacyAct(FERPA)of1974,andwillnotbepartof

youracademic

recordatLasPositasCollege(LPC).



LasPositasCollegeDSPS|InteractiveIntakeApplication



Name:_______________________________



ContactPhone:________________________



Address:_____________________________



W#:_______________________________



City/Zip:___________________________



Birthdate:___________________________

Email(1):____________________________Email(2):___________________________



 Ifwecallyoubyphone,mayweleaveyouavoicemessage?

☐Yes☐No



 AreyouaregisteredLPCstudent?☐Yes☐NoFor howmanysemesters?__________



 Hasyourmathematicsand/orEnglishpl acement beendeterminedatLPC?☐Yes☐No



o ListthehighestlevelmathandEnglishclassesyoutookinHighSchool



Math____________________________English___________________________



 HaveyoucompletedtheLPConlineorientation?☐Yes☐No



 IsEnglishyourfirstlanguage?☐Yes☐No



 Whatothersupportservicesareyoucurrentlyrec eivingatLPC

☐CareerCenter

☐CalWORKs

☐EOPS/CARE

☐FinancialAid

☐HSI

☐MentalHealthServices

☐MiddleCollege

☐Puente

☐TransitiontoCollege

☐Umoja

☐Veteran’sFirst

☐WorkabilityIII

 WhatareyourEducationalGoals? Major:

_________________________________

☐AssociateDegree&transfer

☐AssociateDegreewithouttransfer

☐Transfer

☐EarnaVocationalCertificate

☐Acquirejobskills

☐Updatejobskills

☐PersonalEnrichment

☐Improvebasicskills(i.e.,English,Math)

☐Undecided

☐Other

 HaveyoureceivedDSPSservicesatanothercollegeor

university?☐Yes☐No



 Ifyes,whichcollege/university?__________________________Dates:______________



 AreyouaclientoftheDepartmentofRehabilitation?☐Yes☐No



DORCounselorName:__________________________Phone#:_______________________



 Areyou(orhaveyoueverbeen)aRegionalCenterclient?☐Yes☐No



Ifyes,listtheRegionalCenter(s):________________________________________________



 Inhighschool,Iwasinorhad(checkallthatapply):

☐Regularclasses

☐Specialdayclasses

☐Resourceprogram

☐IEP

☐504plan

☐Other_____________________________



 Selectalldisabilitiesthatapplytoyouandbrieflyexplainhowitaffectsyourlearning.



AcquiredBrainInjury_______________________________________________________



AttentionDeficitHyperactivityDisorder________________________________________



AutismSpectrum__________________________________________________________



Blind/LowVision_______________________________________________________ 



Deaf/HardofHearing____________________________________________________



IntellectualDisability_______________________________________________________ 



LearningDisability_________________________________________________________



MentalHealthDisability_____________________________________________________



PhysicalDisability__________________________________________________________



Other____________________________________________________________________



 Doyouhavedocumentationverifyingthisdisabilityordisabilities?☐Yes☐No



 Doyouhaveaphysicianwhocanverifythisdisabilityordisabilities?

☐Yes☐No



 Areyoucurrentlytakingmedication?☐Yes☐No



o Ifyes,givethenameofthemedication,dosage,andlistthesideeffects:



____________________________________________________________________________



____________________________________________________________________________



 Pleaselistoneemergencycontact



Name:________________________________



Phone(1):_____________________________

Relationship:__________________________



Phone(2):_____________________________



StudentSignatureDate    



DSPSSignatureDate    



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Interactive Intake Application (Las Positas College)

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Completed 24 July 2020

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