Intake Form

* indicates a required field

Student Information

Please enter your information
Please use your university issued email address
he/him/his, she/her/hers, they/them/theirs, etc.
Are you an incoming freshman or transfer student?Required
Date of BirthRequired
Do you have a declared major or have you filed a degree plan?

Specific Accommodation Information

{"display_name":"Disability\/Condition","hidden_field_name":"ms_field_1","init_id":"ms_field_1","init_link":"","has_autocomplete":false,"has_hierpicklist":null}
Do you work with a Texas Workforce Counselor?
Are you requesting to have an Emotional Support Animal (ESA)?
Upload supporting document(s)

Authorized to Release Professional Confidential Information

Instructions to the Client: 
Make sure the appropriate boxes are checked for your approval.

Make sure the release of information is in your best interest.

The primary purpose of this release is to help ensure my receiving course, or other ADA approved accommodations.  I understand it will be in effect during the duration of my enrollment at Prairie View A&M University. However, I may withdraw my approval for release of information at any time.

Restrictions
As with our own records, any information you authorize other professionals to release to this facility will be held strictly confidential.

Permission/AgreementRequired
I give my permission to the Office of Disability Services of Prairie View A&M University to receive full medical, educational, or other pertinent information from appropriate professional agencies or sources. 
In addition, authorize the professional staff members of the Office of Disability Services of Prairie View A&M University to release information about me to:Required






ADA Grievance Procedures and Complaint

I was informed of the ADA Grievance Procedure.  Information can be found on the Prairie View A&M University homepage www.pvamu.edu./disability 

I understand that I am responsible for reading the website information and the confidential ADA Complaint Form is located on the disability services website under the forms tab.