REQUEST FOR SPECIAL NEEDS ACCOMMODATIONS

Personal Information

Name: *

CWID: *

Address: *

DOB: *

Month

Day

Year

Phone: *

ULM Email: *

Racial/Ethnic Background: *

Gender: *

Marital Status: *

Referred by: *

Self

Friend

Faculty/ Staff

Other

Other:

Academic Information

Other

Entrance Date: *

Month

Day

Year

Major: *

Academic College: *

Disability Information

Please describe your disability and its impact in the university setting. *

List the accommodations you are requesting in an academic setting. *

List the accommodations you are requesting in a university-owned residential setting, if applicable.

Describe auxiliary aids, assistive technology and/or services that you anticipate using while attending ULM, if applicable.

Accommodation History

Disability Accommodations and/or Services used in High School:

Colleges/Universities Attended:

List Disability Accommodations and/or Services Used There:

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.

Student’s Name

Date:

Month

Day

Year

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