Name: __________________________ 			Student ID# __________________________ 

Impact of Disability

Please state your primary disability. __________________________________________________________________

Please list any additional disabilities. _________________________________________________________________

______________________________________________________________________________________________

Who diagnosed each disability (-ies) and when were the diagnoses made? ___________________________________

______________________________________________________________________________________________

Please describe the impact of each disability. _________________________________________________________
Please describe how your disabilities affect you academically. __________________________________________________________________________________________________________________________________________________________________________________________________
Describe the variability of your condition. Is it stable, or do you experience flare-ups? What triggers your flare-ups?
_________________________________________________________________________________________________

______________________________________________________________________________________________
Medications
What medications and dosage amounts do you take? Who prescribes your medications? ______________________ _____________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Do you experience any significant side effects? Please name the medications causing side effects and explain how the side effects limit your functioning: ___________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Treatment
Do you receive ongoing medical treatment?  Yes______	 No_______ If yes, please explain frequency, provider, and treatment, if applicable to your request for disability accommodations: _____________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Are you receiving any ongoing mental health treatment? Yes_____   No______If yes, please explain frequency, provider, and treatment, if applicable to your request for disability accommodations: 
____________________________________________________________________________________________
CURRENT FUNCTIONAL IMPACT OF DISABILITY
In which of the following areas do you currently experience functional limitations due to your disability? 
READING
_____Reading comprehension					_____Reading rate/speed

MATH
 _____Solving word problems					_____Math careless errors	
 _____Math rate/speed/fluency					_____Remembering math formulae or skills

NOTE-TAKING
_____Listening to professors/lectures				_____Note taking from lectures		
_____Note-taking from board or overhead screen		_____Note-taking during reading

WRITING
_____Writing paragraphs	   _____Computer skills		_____Using a pencil or pen to write
 ____Grammar mistakes					_____Spelling errors			
_____Punctuation errors	  				 _____Using your own words (avoiding plagiarism)

SCIENCE
_____Science concepts		    				_____Science lab skills	

ATTENTION
_____Maintaining focus in class	    				_____Maintaining focus on homework
_____Completing/submitting assignments on time		_____Hyperactivity		
_____Staying awake in class					_____Staying awake to do homework

MEMORY
_____Retaining concepts 	  _____Memorizing information	_____Remembering vocabulary
_____Short-term memory	_____Long-term memory

MOBILITY/PHYSICAL

_____Walking on campus	 _____Walking up/down stairs	_____Sitting in class/Positioning
_____Fatigue easily		 ______Heat intolerance	_____Cold intolerance
_____Muscle spasticity	 ______Pain (describe location & intensity): ________________________

ACADEMIC PROGRESS

_____GPA Concerns			_____Concerns about financial aid/scholarship requirements
 _____Creating daily schedule		_____Advising		_____Creating semester schedule

TESTING

_____Testing—not enough time					_____Testing—anxiety

MENTAL HEALTH CONCERNS

_____Stress management					_____ Depression
_____Anxious about attending class				_____Anxious about speaking in class
_____Anxious about working in groups  				_____Alcohol and/or drug use
_____Eating disorder						_____Isolation		
_____Sleep disorder 			_____Sleep too much	_____Lack of sleep
	
Consider the major categories of CURRENT functional limitations listed above and then circle the TWO categories that are of greatest concern to you     READING    MATH    WRITING   SCIENCE	NOTE-TAKING   ATTENTION   MEMORY	
MANAGEMENT OF SELF AND TIME    MOBILITY/PHYSICAL    SELF-DETERMINATION      TESTING    MENTAL HEALTH

Student Information Worksheets								
Name: __________________________________________ Student ID: ___________________________________
Permanent/Home
Address_________________________________________City______________ State__________ Zip __________
TCU/Local
Address_________________________________________City______________ State__________ Zip __________
Permanent Phone: (         )______________________	Local Phone: 	(         )_____________________________
Cell Phone: (        )___________________________	TCU e-mail address_______________________________
 Gender: ____________				Date of Birth	______/______/________
Indicate where you are or will be living during the school year:
_____At home with parents/guardians		    	_____In your own apartment
_____In on-campus residence hall_____________	    	____In another setting________________
What is your classification? (FR, SOPH, JR, SR, GRAD, Non-degree)_______________________________
High School Data (include name of school(s), location, dates attended, and date of graduation or GED completion)
High School(s): ______________________________________________________________________________
When did you graduate? ______________________ H.S. Grade Point Average_________
 Did you have an academic accommodations plan during your Kindergarten--12 school years?  If yes, for what disability(ies)?__________________________________________________________________________________
If yes, for which grades:  K-2  _____ 3-5 _____ 6-8_____ 9-10_____ 11-12_____
Describe the academic adjustments, accommodations, and services you received in high school, including tutoring, testing, extended time, and location where services were provided and for which subjects: _____________________________________________________________________________________________
**You will need to contact your high school to request that your disabilities-related records be sent to the Student Disability Services office.**
Have you worked with an academic success coach? When? Frequency? How did the coach help you? _________
___________________________________________________________________________________________
Did you use auxiliary aids, adaptive equipment, or alternative format texts? If yes, please list:_________________
____________________________________________________________________________________________

Did you have accommodations for a non-ADHD medical condition or a physical/systemic illness or injury? Explain:
__________________________________________________________________________________________________
Did you work with a counselor or mental health provider? ________ If yes, during which grades? ______________
College Entrance Examination(s)
Did you apply for accommodations on any of the following examinations? (Check all that apply.)
ACT ______ SAT ______ Advanced Placement ______ GRE ______ GMAT ______
Were any of your accommodation requests denied?  If so, which ones?____________________________________
For the SAT and ACT exams, please indicate the following:
Test	     Regular Time		Extended Time		Additional Accommodations Used		
SAT	   	 □		       □		     ______________________________________________
ACT            	 □		       □		     ______________________________________________	
ACADEMICS
What is your major?_________________________  Academic Adviser?______________________________
Have you changed your major since starting college?  _____ If so, from which one?_______________
Will you participate in extracurricular activities during school? (fraternity/sorority, campus clubs, athletics, etc.)  
Yes______       	No______ 	If “Yes” please describe and provide # of hours per week _______________
Will you work during the school year? Yes  No  (circle)  # hours per week: __________________ 
Will you have more than one place of employment? _________________
Do you plan on attending graduate school, and if so, what program? _____________________________________
Who referred you to our office or how did you find out about the office?__________________________________
Do you work with a TCU Campus Life Dean? If yes, name of Dean: ________________________________________
Post-Secondary Data- (Community Colleges/Other Universities attended)
Are you a transfer student?  ________________ What semester did you start at TCU? _______________________
Grade Point Average: _________  # of Hours Completed: ____________Major:_____________________________ 
Name of post-secondary school(s):_________________________________________________________________
_____________________________________________________________________________________________
Dates attended:  _________________________ Did you receive assistance from Disability Services? __________

What types of services/accommodations/auxiliary aids did you receive at previous colleges/universities?
____________________________________________________________________________________________
_____________________________________________________________________________________________
What services and/or accommodations do you anticipate needing at TCU? _____________________________________
__________________________________________________________________________________________________
**You will need to contact previous colleges/universities attended to request accommodations records be sent to TCU’s Disability Services.

Student signature ________________________________________________________________________ Date ____/____/_____
Disabilities Specialist signature _____________________________________________________________Date ___/____/______