Accommodation/Disability Request

Date of Request

Date of Request(Required):

This field is required.

Student Requesting Accommodations

Student Name

Student Sex

Student ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Supplemental Information

The information that you provide here will be used to assist the University in determining reasonable accommodations. Please make sure to include relevant documentation in the Supporting Documentation section to expedite this process. After the request has been made, the Director will determine if the student qualifies for accommodations.

What is your diagnosis, according to the DSM-V?(Required) This field is required.

Please provide any clinical and background evaluation information as to how the diagnosis was made, and what the assessment process entailed.(Required) This field is required.

Please provide an explanation for the ruling out of other diagnoses.(Required) This field is required.

Please provide an account of your medical and academic history.(Required) This field is required.

What are your current symptoms? This can include examples of the impairment(Required) This field is required.

What specific accommodations are you requesting?(Required)

Extra time Change of venue OTHER THINGS

You must make at least one selection.

Please list the contact information for any and all individuals completing the evaluation (name, address, phone number, & qualifications).(Required) This field is required.

What is the date of the evaluation? (YYYY-MM-DD)(Required) This field is required.

Supporting Documentation

Please attach any supporting documentation for your request. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Date of Request

Student Requesting Accommodations

Supplemental Information

Supporting Documentation

Submission