Intake Form

Student Information

Please enter your information

Are you already receiving services with the DRC?

First Name

Last Name

Middle Name

Preferred Pronouns

Student ID

Please write your full number, including the capital E.
Example: E0012345

EMich Email Address

Please use your @emich.edu email address to avoid delays in processing your request.

Phone Number

Current Address

Academic Information

Major(s)

University Support Programs

Please only check the following boxes if you have been formally accepted into the listed programs

Current Class Standing

First Semester at EMU

Additional Colleges or Universities You Have Attended

Disability and Accommodation Information

Have you previously received accommodations from the Disability Resource Center?

Please select all diagnoses that impact you

If other (explain below):

Temporary or Long-Term

Is this a temporary injury or long-term disability related accommodation request?

How does your disability affect you academically?

How does your disability affect student life in general, like taking tests and studying?

Please describe the accommodations you are requesting:

I will require the following to be present for my meeting with the DRC:

Other Requirements:

Upload supporting document(s)

Please upload all medical documentation that supports your requests for accommodations.
If you do not have documentation, please download the DRC Physician Form to bring to your physician to complete.

Questions/Concerns

If you have any questions or concerns, please email the DRC at drc@emich.edu for a quick response!

Intake Form

Student Information

Academic Information

Disability and Accommodation Information

Document Information