ASC Intake Form

Fill out this form if it is your first time requesting services from the ASC. You only need to complete this form one time. If you are already in contact with the ASC, please use our email address, [email protected], or call 978-867-4743.

1. Full Name (First and Last)

2. Gordon Student ID#

3. Date of Birth (month/date/year)

4. Email Address

5. Cell phone number

6. Class Year at Gordon

7. Do you live on campus?

	Yes
	No

8. If you live on campus, which residence hall do you live in?

9. If you live off campus, what town do you live in?

10. What is your home state or country?

11. Would you like to disclose a disability?

12. What are your reasons for contacting the ASC? Please check all that apply.

	Referred by a professor
	I think I may have a learning disability
	I'm struggling in a class(es)
	ELL/ESL issues
	I am experiencing emotional issues that are affecting my academics
	I need study skills and/or time management help
	Other

13. What's the best way to reach you, email or phone?

Leave this blank
Do not change this

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ASC Intake Form

ASC Intake Form

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