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Intake Form

Intake Form

Accessibility Services
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New Accommodation Request

This form is to be completed by students who are NEW to ACCESSibility Services. Please contact us at 719-502-3333 to schedule your intake appointment.

If you would like to request an interpreter for your appointment, please fill out our online Interpreter Request Form

APPOINTMENT DATE:

I understand that PPCC is not obligated to continue accommodations that have not been reviewed by this office. (INITIAL BELOW) Required

LAST Name, FIRST Name: Required

S Number

Student Email Required

Phone Number Required

Birth Date (mm/dd/yyyy) Required

Gender Identification Required

Disability (identified or diagnosed). Please check all that apply. Required

ADD/ADHD

Asperger's/Autism Spectrum

Blind/Low Vision

Communication Disorder

Deaf/HOH

Orthopedic Condition

Processing Disorder

Psychiatric/Psychological Disorder

PTSD

Specific Learning Disorder

Traumatic Brain Injury (TBI)

Other

*Other Health Condition OR Temporary Disability (specify)

Please list any prescription, over-the-counter, and/ or alternative medication(s) you are taking at this time.

Have you received accommodations in school before? Required

K-12 Education (IEP/504 plan, resource room)

Other college or university

Not Applicable

Please check your STUDENT STATUS: Required

Military Veteran

Active Duty Military

Military Dependent (family member)

High School Concurrent Enrollment

Career Start

Not Applicable

How did you find out about us? (check all that apply) Required

Self-referred

Family/friend

PPCC Instructor

Counselor

Student Success Seminar (Orientation)

High School Teacher or Counselor

PPCC Website.Catalog

Veteran's Affairs

Vocational Rehabilitation

Other

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