6823St.CharlesAvenue Ph:504.862.8433Science&EngineeringLabComplex Fx:504.862.8435Building14,Suite103 goldman@tulane.eduNewOrleans,LA70118 www.accessibility.tulane.edu

Great Minds Think Differently

GoldmanCenterforStudentAccessibilityProviderFormInordertohelpdeterminereasonableaccommodations,qualifiedprofessionalsmaysubmitdocumentationonbehalfofstudentstoprovidetheGoldmanCenterwithadditionalinformation.Thisinformationwillbeusedinconjunctionwiththestudent’sself-report,theGoldmanCenterstaffmember’sstructuredinterview,andtheessentialelementsanddesignoftheclassroom/dining/residentialenvironmenttodeterminereasonableaccommodationsonanindividualbasis.Pleasenotethattheinformationprovidedwithinthisdocumentwillbeconsideredholisticallywithallotherinformationgathered.Specificinformationprovidedwithinwillneitherguaranteethestudentwillreceiveaspecificaccommodationnorpreventthestudentfromreceivingaspecificaccommodation.AllinformationprovidedwillbeconfidentiallyusedbyGoldmanCenterstafftoreachaneligibilitydetermination.Itisnotmandatedthatstudentsusethisform,butitcanaidtreatmentprovidersinsupportingreasonableaccommodationrequests.Student’sName:Diagnosis/esanddatediagnosed:Briefsynopsisoftreatmentanddatelastseen(ex:duration,frequency,natureof):Impactofdiagnosesonfunctioning:Specificrecommendation(s)foraccommodation(s):NameandCredentialsofProvider:_____________________________________________________________Licensenumber:______________________________________Telephone:_____________________________Signature:______________________________________________Date:_______/_______/______________