Office of Health and Counseling Services

Student Accessibility Services Intake Form

"*" indicates required fields

Student's Name*

First Middle Last Suffix

Date of Birth:*

Are you admitted to Delta State University?*

Yes

#900*

Term/Year*

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Student's Phone #*

Home Phone #

Email Address*

Enter Email Confirm Email

Phone

This field is for validation purposes and should be left unchanged.

**Please make sure you frequently check your DSU Email! This is how we will communicate with you as we go through this process.