CONTINUED ON THE REVERSE SIDE L/New Student Questionnaire/sl/3/20
Please complete both sides of this application to the best of your ability.
Name:_______________________________________________________ Student #: ____________________
Address: ________________________________City:____________________ State:______Zip:____________
Phone Number: (Cell)________________________D.O.B._________________
Are you a client of the Department of Rehabilitation? Y N
SELF REPORT - Check and describe all disabilities that apply:
___Acquired Brain Injury: Head injury Stroke Other ____________________ Date: _____________
___Intellectual Disability: Slow learner Intellectual disability Other_______________
___Deaf/Hard of Hearing: Deaf Hard of Hearing I use sign language interpreters
___Learning Disability: I think I might have a learning disability Tested in: High School College
___Physical Disability: Injury Genetic/congenital condition Other _________________________
Affects: Hands/arms/shoulders Feet/knees/legs Back/Neck Use wheelchair
___Mental Health Disability: Depression Anxiety Bipolar Schizophrenia Other______________
___ADHD: Mild Moderate Severe I use a communication device
___Blind/Low Vision: Low vision Legally blind Blind I use: Enlarged materials Audio Braille
___Other Health Condition & Disability: Other medical condition: _______________________
___Autism Spectrum
Are you taking any medication? Y N Specify: __________________________________________________
Do you experience seizures? Y N Describe: ____________________________________________________
Please list your academic major: _______________________________________________________________
What is your long term educational goal? ___AA/Transfer ___AA/General ___Certificate ___Job Skills
___Personal Development ___Other________________________
What is your long term career goal? ____________________________________________________________
CONTACT INFO - Please provide the name and location for any of the following contacts you may have:
Emergency Contact: _____________________________Relationship: ______________Phone:_____________
Dept. of Rehabilitation Counselor:__________________City:_____________________ Phone: _____________
Mental Health Counselor: ________________________ City: _____________________Phone: _____________
Regional Center Counselor: _______________________ City: _____________________Phone: ____________
Please list any other colleges you have attended: __________________________________________________
Please describe any prior vocational training or work experience: _____________________________________
Do you currently work? Y N How many hours per week? __________ Describe: ______________________
Please indicate if you are receiving services or funding from any of these campus or community programs:
SSI/SSDI Financial Aid/Fee Waiver EOPS
CAL Works Veterans Administration Worker’s Comp
How many classes do you plan to enroll in per semester? 1 2 3 4 5 or more
How will you get to campus? Drive Walk/bike Get a ride Bus/metro ACCESS
Services you would like to request from DSPS: ___________________________________________________
Computer proficiency (circle): None Basic Intermediate Advanced
Computer Skills: Internet Word Processing Email
Assistive technology you’ve used (circle): JAWS ZoomText Kurzweil Dragon Alpha Smart Other:_______
Describe: _________________________________________________________________________________
How do you handle stress? ________________________________________________________________
Describe any coping strategies you use: ______________________________________________________
Do you ask questions when you are unsure of what is expected of you? _____________________________
Do you have friends and/or acquaintances on campus? Y N Describe: _____________________________
Do you participate in any extra-curricular activities? Y N Describe: ________________________________
Do you have a stable home environment? Y N Describe: ________________________________________
Please indicate if you have difficulty with any of the following activities and briefly describe your issues:
Do you have difficulty:
Managing your time?
Taking notes in class?
Completing assignments?
Taking exams?
Participating in class?
Remembering important information?
Concentrating in class?
Concentrating while studying?
Concentrating during exams?
Communicating with your instructors?
Communicating and interacting with
other students?
Managing your emotions?
I wish to apply to Disabled Student Programs and Services. The information I have provided is true and
accurate to the best of my knowledge. I understand that the application materials I have submitted will be
reviewed by a specialist to determine my eligibility for services and that further documentation may be
Signature: _________________________________________________________ Date: __________________
I UNDERSTAND AND ACCEPT that by providing my full name in lieu of the electronic
signature, I am acknowledging my agreement with the acceptance of these statements.
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