Special Needs Support Application Form Template

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Special Needs Support Application Form Template

Dear student, your journey is important to us. By understanding your unique needs, we aim to create a supportive and enriching university experience for you.
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*Your name:
*Your contact information:
Email address
Email address
Phone number
Phone number
*What is your current academic status?
Undergraduate student
Graduate student
Doctoral candidate
Other (Please specify)
*Which types of special needs support services are you seeking? [Checkboxes]
Academic accommodations (e.g., note-taking assistance, extended test time)
Assistive technology (e.g., screen reader software, audio recorders)
Physical campus modifications (e.g., wheelchair accessibility, ergonomic furniture)
Mental health services (e.g., counseling, stress management workshops)
Peer mentoring and support groups
Career counseling and internship support tailored to students with disabilities
Other (Please specify)
*What is the primary reason for seeking support at this time?
Newly diagnosed condition
Transitioning to a more challenging academic environment
Previous accommodations were insufficient
Other (Please specify)
*Please indicate the nature of your disability or special need. [Checkboxes]
Learning disabilities (e.g., dyslexia, ADHD)
Physical disabilities (e.g., mobility issues, visual or hearing impairment)
Mental health conditions (e.g., anxiety, depression)
Chronic health conditions (e.g., diabetes, autoimmune diseases)
Temporary disabilities (e.g., injury recovery)
Other (Please specify)
*How do you prefer to communicate with the special needs support office?
Email
Phone
In-person meetings
Video conferencing
Other (Please specify)
Is there any other information or specific accommodations you believe are important for us to know?
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