• Image field 3

  • Center for Accessibility and Disability Resources Application

  • Student Intake Form

    Please answer the following questions to help us better determine your needs. Your responses are confidential.

    Requests for accommodations may require the submission of appropriate documentation. Please see Documentation Guidelines for specific information.

    You must make an appointment for an intake interview to discuss your needs.

    If you are requesting accommodations for the College placement testing be sure to link with the Center for Accessibility and Disability Resources prior to testing.

    Please allow sufficient time to process an application with our office. Generally, 2 to 4 weeks ahead of the start of a semester is required.

  • Today’s Date:*
     / /

  • Personal Information

  • Date of Birth:*
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Current Status at Middlesex College:*
  • Are you currently enrolled in the Dual Enrollment Program with Middlesex College?*
  • Are you a visiting student from another college or university?*
  • Are you working with the Division of Vocational Rehabilitation?*

  • Reason for Referral

  • Who referred you to Disability Services? (Check all that apply)*

  • Requests:

  • Have you applied to Middlesex College through the College’s Admission Office?*
  • Have you taken the College Placement Test?*
  • Are you requesting testing accommodations?*

  • Academic Information

  • Were you classified in Special Education in High School?*

  • Medical History

  • Have you ever had a neurological or neuropsychological exam?*
  • Do you have a hearing problem?*
  • Do you wear hearing aids or use sign language?*
  • Do you have a vision problem?*
  • Do you wear contacts or glasses?*
  • Do you have a physical condition that makes writing difficult?*
  • Do you have a physical condition that makes getting around difficult?*

  • Psychological History

  • Have you ever been diagnosed by a professional as having a Learning Disability?*
  • Have you ever been diagnosed by a professional as having Attention Deficit/ Hyperactivity Disorder?*
  • Have you ever been diagnosed by a professional as having psychiatric/psychological condition?*
  • Are you currently in treatment for the condition?*
  • Have you ever been hospitalized due to your psychiatric condition?*

  • Assistive Technology Assessment

  • Have you ever been evaluated to use any assistive technology?*
  • Do you currently use this technology?*
  • Did you use any assistive technology in High School?*

  • The information contained in this form is true and accurate to the best of my knowledge.

  • Date*
     / /
  • Should be Empty: