Self Disclosure Intake Form

Student Information

Please enter your information

Last Name

Please write your last name as it appears on your College ID.

Middle Name

Student ID

Do not include @ sign. Please enter your 8-digit student ID number (e.g. 01234567). 

State Community College Email

Please use your email ending in @mail.ct.edu

Personal Email

Please note that Disability Services will contact you through your CT State Community College email address, ending with @mail.ct.edu for scheduling. 

Phone Number

Have you been approved for accommodations by one of the CT State Community College legacy campuses before?

First Name

Please write your first name as it appears on your College ID.

Academic Information

What is the first semester for which you are seeking accommodations?

Disability and Accommodation Self-Report

Please use this space to indicate any of your diagnosed disabilities

How does your disability affect you academically?

If relevant, how does your disability affect you non-academically?

What accommodations/modifications have been helpful in the past?

Please understand that this does not guarantee specific accommodations will be approved.

What academic accommodation (s) are you requesting?

Please understand that this does not guarantee specific accommodations will be approved.

Is there any additional information which you would like to include? 

If you selected other, please explain

Documentation

Documentation Guidelines

Agreement

The Office of Disability Services will review your request as soon as possible. We will contact you by through your CT State Community College email to schedule an intake interview for our interactive process. Please understand that submitting your request does not guarantee academic accommodations.

Agreement to initiate full process Required

Self Disclosure Intake Form

Student Information

Academic Information

Disability and Accommodation Self-Report

Document Information