Intake Form

Disability Services Intake Assessment

LSUA Disability Services organizes services for qualified students with disabilities requiring reasonable accommodations. Notifying LSUA that you have a disability is optional.

If you have a disability and need to request accommodations, please complete the following information. After completing the form, you will also need to make an appointment for an intake meeting with the DS coordinator (disabilityservices@lsua.edu or call 318-427-0137).

First Name

Phone

Last Name

E-Mail

Address

City

State

Zip Code

If you are transferring from another college, please state the name of the college and list support services you have received.

Are you receiving assistance from Veterans Administration?

Yes

Are you receiving assistance from LA Rehabilitation Services?

Yes

Academic Program

How does this disability impact you in the academic environment (how it impacts your learning)?

Please indicate what kind of accommodations you are requesting.

New code

Please type the code above

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Student Signature

Today's Date

The Coordinator of Disability Services will reach out to you to provide more information on the required documentation and next steps.

LSUA does not discriminate or harass on the basis of race, color, national origin, sex, gender, sexual orientation, disability, age, religion, genetic marker, or any other characteristic protected by state, local or federal law, in our programs and activities.