REQUEST FOR SPECIAL NEEDS ACCOMMODATIONS

Personal Information
Academic Information
Disability Information
Accommodation History
Certification

I certify that the information provided on this form is accurate. I understand that to be eligible for special needs accommodations at ULM, I must 1) submit this completed form, 2) submit disability documentation that substantiates the requested accommodations, and 3) participate in an intake interview with a Counseling Center staff person.My signature authorizes the Counseling Center to discuss my documentation with the clinician who authored the documentation if additional information or clarification is required.

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