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Request for Services Form

* indicates a required field

Student Information

Please review and answer the following questions thoughtfully. You may consult with a teacher, guidance counselor, or parent, but the answers should be your own. We will review these question and answers during your intake meeting. In additional to the self-reported information, all requested accommodations will need to be supported by documentation from a qualified evaluator prior to approval (see Documentation Requirements at www.mitchell.edu/access).

This questionnaire is for information and planning purposes. It does not guarantee the student will receive a specific accommodation or that services will be in place when classes begin.

What to expect: Once Accessibility Services has received this completed Request for Services Form and appropriate documentation has been received:

Students will meet with Accessibility Services in person or virtually. Students will receive an email inviting them to do so when their materials have been reviewed.
Accessibility Services will review accommodations, procedures, and policies at the meeting and copies of Accommodation Letters will be created for each appropriate class and/or staff member. Residential accommodations will be communicated to the Office of Residence Life.
Students will be responsible for discussing accommodation with instructors and report any unresolved issues to Accessibility Services.

First NameRequired *

Last NameRequired *

Middle Name

Student IDRequired *

EmailRequired *

Please use your Mitchell College issued email address

Phone NumberRequired *

Enrollment StatusRequired *

Have you applied for the Benson Learning Center? Required *

Have you applied for the Benson Learning Center? Yes Have you applied for the Benson Learning Center? No

Acknowledgement of Policies

DocumentationRequired *

Please check the statement to acknowledge.

I understand I will be responsible for forwarding documentation from a qualified evaluator, verifying my disability and stating the impact of my disability to Accessibility Services (see documentation requirements).

Accessibility Needs QuestionnaireRequired *

Please check the statement to acknowledge.

I will complete the following Accessibility Needs Questionnaire and will discuss accommodations with Accessibility Services.

ReleaseRequired *

Please check the statement to acknowledge.

I must sign the release below to allow files and referrals to/from other departments on campus to be made.

Fee based programRequired *

Please check the statement to acknowledge.

I understand that this is NOT an application to the fee based program (BLC).

ConfidentialityRequired *

Please check the statement to acknowledge.

I understand that all documentation will be handled in a confidential manner.

Specific Accommodation Information

Nature of DisabilityRequired *

Please check all that apply

I am requesting academic accommodationsRequired *

I am requesting academic accommodations Yes I am requesting academic accommodations No

I am requesting residential accommodationsRequired *

I am requesting residential accommodations Yes I am requesting residential accommodations No

I am requesting campus access accommodationsRequired *

I am requesting campus access accommodations Yes I am requesting campus access accommodations No

I am requesting other accommodations.Required *

I am requesting other accommodations. Yes I am requesting other accommodations. No

Accessibility Needs Questionnaire

Questionnaire

Please review and answer the following questions thoughtfully. Questions that do not apply can be answered with N/A. You may consult with a teacher, guidance counselor, or parent, but the answers should be your own. We will review these question and answers during your intake meeting. In additional to the self-reported information, all requested accommodations will need to be supported by documentation from a qualified evaluator prior to approval (see Documentation Requirements).

This questionnaire is for information and planning purposes. It does not guarantee the student will receive a specific accommodation or that services will be in place when classes begin.

Please describe your disability/disabilities to the best of your understandingRequired *

How does your disability affect your ability to physically access buildings, classrooms, or campus facilities?Required *

Answer N/A where appropriate

What residential accommodations are you requesting?Required *

Answer N/A where appropriate

Do you require any special equipment or assistance for emergencies?Required *

Answer N/A where appropriate

Do you require any special equipment or assistance during residential emergencies?

Please explain other anticipated campus access needsRequired *

Answer N/A where appropriate

Please explain other anticipated residential access needs

How does your disability affect you when reading?Required *

Answer N/A where appropriate

How does your disability affect your ability to write?Required *

Answer N/A where appropriate

How does your disability affect your ability to take notes?Required *

Answer N/A where appropriate

How does your disability affect your attention?Required *

Answer N/A where appropriate

How does your disability affect your communication with others (hearing, seeing, speaking, etc.)Required *

Answer N/A where appropriate

How does your disability affect your ability to access required course materials?Required *

(Computers, written handout materials, movies, technical equipment, etc. Answer N/A where appropriate)

How does your disability affect you when taking tests?Required *

Answer N/A where appropriate

What classroom accommodations are you requesting?Required *

Answer N/A where appropriate

What testing accommodations are you requesting?Required *

Answer N/A where appropriate

Do you plan to request textbooks in an alternate format for your courses?

Do you plan to request textbooks in an alternate format for your courses? Yes Do you plan to request textbooks in an alternate format for your courses? No

What other accommodations are you requesting?Required *

Authorizations

AuthorizationsRequired *

I make the following authorizations listed below regarding the release of information pertaining to me for the purpose of assisting me in my program as well as in determining reasonable accommodations: (Check to indicate authorization)

I permit Accessibility Services to contact other professionals who have evaluated or treated me including physicians, psychiatrist, and/or the Office of Health and Wellness at Mitchell College to further discuss and/or obtain additional information regard I permit Accessibility Services to discuss accommodation information with appropriate faculty and staff. I give my permission for all relevant information and documentation to be shared from/with the Bentsen Learning Center or Thames at Mitchell for purposes or application or accommodations.

Upload supporting document(s)

If you are applying for academic accommodations and already applied to the Bentsen Learning Center (BLC) or Thames at Mitchell College, you do NOT need to resubmit your documentation. However, please ensure that you gave permission above for all relevant information to be shared between programs above in the Authorizations section of this form.

Document Information

Document Title

FileRequired *

Maximum file size: 10240kb

Description