VCU logo   Division for Academic Success

Student Intake

Please complete the intake form to register for our office. It should take about 20 minutes to complete. All information provided is secure and confidential. Thank you!

 

* Required
Are you in the College of Health Professions, School of Dentistry, School of Medicine, School of Nursing, or School of Pharmacy?*  
   

Contact Information

First Name*  
Middle Name
Last Name*  
  V-Number* V (Enter 8 digits) 
Pronouns
Address  
City       
State    Zip 
 
    Phone Number * (###-###-####)
 Email*  
   

Emergency Contact Information

Name
Relationship
Best Phone Number (###-###-####) 

Program Information

 School*




Are you aware of the Technical Standards of your program?*  
   

Reason for Request

Referral Source



Reason(s) for visit*
Documented Disability










 

Current Management

Are you currently working with a case manager, health professional, or mental health professional of whom we should be aware?