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Intake Questionnaire for Student Participants
Intake Questionnaire for Student Participants

* indicates a required field.

Personal Information

Today's Date:
Your Full Name:*
What do you like to be called (nickname if any)?
Your Age:
Your birth date (MM/DD/YYYY):
Your full home address:*
What is the phone number where we can most easily reach you?*
What email address do you prefer we use if we need to email you?*

Campus Life

Will you live on campus? Yes or No
Name of Residence hall (if known):
Single room or With roommates(s)
If roommates, how many?
Roommate(s) names (first names only, if known):

Educational Information

What was the name of your High School(s)?
Public or Private
What year did you graduate?
How were your classes structured in High School (ex. Small groups, regular classes, individual instruction, advanced placement, college coursework)?
Favorite subject(s) in high school:
Least favorite subject(s) in high school:
What comes easy for you academically?
What challenges you academically?
Did you receive any support services or accommodations in high school? Yes No
If so, please explain.
Will you be requesting academic accommodations at RIT? Yes No
What were your SAT/ACT scores?
Did you attend any other colleges or universities prior to coming to RIT? Yes No
If YES, where did you go?
What did you study there?
What semester standing are you at RIT?
Incoming First Year 2nd Year 3rd Year 4th Year
What school/college are you enrolled in (i.e. College of Engineering)?
Who is your academic advisor (if known)?
If you have declared a major at RIT, what is it?
If you have not declared a major, what are you considering?
Why did you choose this major?
Does your major require co-op experience(s)? Yes No Not Sure
If yes, how many experiences are required?
What is your dream job?

Work Experience

Have you ever worked? Yes No
If YES, where were you employed?
What were your duties at this job?
Have you ever done volunteer work? Yes No
If YES, where?
How did you volunteer (i.e. what did you do)?
What skills do you think you have developed from your work and/or volunteer experiences?

Treatment/Medical Information

What is your diagnosed disability?*
When were you diagnosed?
When was your last assessment done?
By whom?
If you were to describe your diagnosis and how it affects you, what would you say?
Are you currently working with a therapist or counselor? Yes No
Do you plan to continue working with your therapist/counselor while you are at RIT? Yes No
If so, how often will you meet with/talk to him/her?
What medications are you currently taking?
Please describe any side effects associated with your medications.
How will you obtain you medications while at RIT?

Parents/Family Information

Parent/Guardian #1

Cell Phone

Parent/Guardian #2

Cell Phone
Do you have any siblings?
Yes No
If so, what are their names and ages?



Describe your current living arrangements (for example, at your parents house, in your own room).
Describe your living habits (i.e. your privacy needs, orderliness, etc.)
Do you have a driver's license?
Yes No
Have you ever used public transportation (public buss, subway)?
Yes No
Do you plan to have a car on campus?
Yes No


What particular situations trigger a stress response in you?
How do you cope when you get very afraid?
How do you cope when you get very anxious?
How do you cope when you get very frustrated?

Social Interactions Tell us a little bit about your relationships with other people.

What are some common social challenges you experience?
At the end of the day, how do you unwind?
What do you most enjoy doing with your downtime?

Fall Course Schedule

I give SSP staff permission to work with my academic department (advisor in my major) on building a fall course schedule that best meets my needs (ex: appropriate course load, balanced schedule)

Transition/Success at RIT

What are you most worried about adjusting to in your transition to RIT?
What have you done to prepare for your transition or success at RIT?
Other things you'd like us to know about you:

Thank You. We Look Forward to Working with You!

One of more required pieces of information has been left blank. Please review the form and enter required information and then submit the form.

Laurie Ackles
Spectrum Support Program
Rochester Institute of Technology

PHONE: (585) 475-6936
FAX: (585) 475-5832
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