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New-studentintakeform

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PEPPERDINE UNIVERSITY
DISABILITY SERVICES OFFICE
STUDENT INTAKE FORM
Information provided in this request will be treated as confidential information. Even if you are submitting
additional documentation along with the request, it is important you respond to all the questions as best
you can and sign the last page. If you need assistance, please seek help from the DSO staff.
Name____________________________________ Date_____________
Local/School Address______________________________________________________
_______________________________________________________________________
Permanent Home Address__________________________________________________
_______________________________________________________________________
Phone__________________________ Cell__________________________
Student ID#_____________________________
Seaver ______ GSBM _______ GSEP _______ SPP _______ SOL _______
Seaver Enrollment Status (Freshman, Sophomore, Junior, Senior): _________
Graduate: Program Name _________________________________________
1. What is the nature of the impairments for which you are requesting services?
Check any that apply.
___ Learning Disorder ___ Attention Deficit Disorder
___ Hearing Impairment ___ Visual Impairment
___ Physical Limitation ___ Psychiatric Disorder
___ Other (please specify) _____________________________________
2. Please briefly describe your current impairment and any relevant diagnosis.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
3. When were you first diagnosed with the condition you consider disabling? If
there is more than one condition, please list them separately.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Submit Form Now
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4. Describe how your impairment(s) impact(s) your functioning. ____________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
5. What accommodations are you requesting at Pepperdine University?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
6. Describe in detail the accommodations you have received in the past,
including the nature of the accommodation(s), the names of providing institutions,
and the dates provided.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
7. When, where, and by whom were you most recently evaluated/treated for the
condition(s) that cause your impairment? Please indicate the title and credential of
the evaluating professional.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Thank you for your cooperation. You will find specific information on our website,
www.pepperdine.edu/disabilityservices, about the type of documentation necessary
for each type of impairment. If you have any questions, please contact us directly
at 310-506-6500.
A review of your documentation relating to your request will not be commenced until
this form and all supporting documentation have been received. We do not review
materials until your file is complete. Upon receipt of all documentation, your file will
be reviewed, a process that typically takes no less than 14 days. PLEASE DO NOT
SEND ORIGINAL COPIES OF DOCUMENTATION. WE DO NOT RETURN
MATERIALS ONCE SUBMITTED.
By signing below, you are initiating your request to be established as a student with
a disability in accordance with federal and state regulations.
__________________________________ _____________________
Student initials Date
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Completed 16 December 2019

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