CSUMB Clinic for Educational Supports Intake Form
Thank you for your interest in receiving services from the CSUMB Clinic for Educational Supports. Please fill out the information below and someone will be in contact as soon as possible. If you would like to check on the status of your request, please email ces@csumb.edu

**All information will be kept confidential.

Thank you!!

DO NOT FILL OUT THIS FORM IF YOU ARE A CURRENT CSUMB STUDENT IN NEED OF SDAC ACCOMMODATIONS, REACH OUT TO SDAC DIRECTLY FOR OUR SHARED PROCESS (sdac@csumb.edu).

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Email *
Child's Name *
Date of Birth *
MM
/
DD
/
YYYY
Age *
Parent/Guardian's Name *
Phone *
email *
Person Referring Student *
School
If you are a current CSUMB student, you MUST reach out to SDAC directly for our shared process (sdac@csumb.edu).
Briefly explain why the student needs an assessment. *
Is student currently receiving services? *
Times for Potential Assessment Dates
Completing this section does not guarantee that your child will participate in an assessment.  
Preferred Days
Preferred Time of Day
How did you hear about CES? *
Required
If applicable, referred by:
A copy of your responses will be emailed to the address you provided.
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