New Student Accommodation(s) Request

First Name

Middle Name

Last Name

Student ID

Email

Please use your CSS issued email address

Phone Number

Please state and describe your disability/chronic medical condition/mental health diagnosis as you understand it.

Please include the date of onset (date it started and was diagnosed).

Please describe who and what condition

Please explain how your disability affects you in the learning AND/OR living environment

Please describe the settings in which these symptoms have been most evident (occur most)

Please rate, from no impact to severe impact, how your disability limits your life activities in the following areas

Please describe any additional impact(s) on your life activities below

What are some other issues, concerns or life circumstances that are affecting you at this time?

(stress, work, family/intimate partner problems, illness, homelessness, etc)

What medications, if any, are you on because of your disability? Do you have any side effects with the particular medication?

What type of accommodations do you feel would be needed? Why?

The Center for Equal Access Intake