Parkland College

ACCESSIBILITY SERVICES: Intake Form













General Information

Gender:   



Ethnicity:



Primary Language:      

        
     

Educational goal at Parkland College:
        








Planning to transfer to a 4-yr. institution?
  














Disability Information








Rate your performance on these tasks by checking if it represents a strength for you or if you have difficulty in that area:
Hearing

Seeing

Speaking

Listening

Walking

Endurance

Paying attention in class

Completing assignments

Writing/taking notes

Understanding what I’ve read

Managing time/organizing

Doing math word problems

Doing math calculations

Reading words/sentences

Memorizing

Following directions

Spelling

Writing essay answers

Proof reading

Being motivated

Talking with instructors


Have you ever experienced difficulties with any of the following?




Are you currently taking any disability related medications?   




Are you currently receiving counseling or therapy?   



Check the following types of assistive technology that you have used:






Employment/Work Experience

Are you currently working?