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Office of Disability Services

Student Self Referral Form for CURRENT STUDENTS

New Students - Please select New Student Self Referral link on left.

Student:
ID#
Phone:
Number of Credits Taking:
Previous diagnosis/history of disability/special education?

Areas of Concern

  (check all that apply):
Keeping up with classwork
Staying focused
Completing Assignments
Taking Tests
Organization
Depression
Negative attitudes
Lack of motivation
Relationships
Showing up late for class
Missing classes
Specific courses of concern:

Other comments/concerns: