Disability Services Initial Accommodation Request

* indicates a required field

Student Information

Thank you for beginning the accommodation request process with Disability Services (DS). This form is intended to provide a space for you to share your experiences and perspective with DS staff. It is a starting point from which, together, we will determine your accommodations. Disability Services will not receive this Initial Accommodation Request form until you click on the SUBMIT button. Once submitted, you cannot edit this form.

First Name

Last Name

Student ID

Please use your Mount Holyoke email address

Click here to add Disability Information

For each disability, please provide the following information

● Diagnosis

● Onset

● Symptoms & Functional Impacts

● Treatment

Specific Accommodation Information

The following questions are all optional for those students who wish to provide additional information prior to their initial accommodation request appointment. A history of having previously received accommodations is not required in order to be approved for accommodations here at Mount Holyoke College.

Please check the box if you were on a 504 Plan or an IEP in High School

Please list any accommodations that you received in High School

Please list any accommodations that you anticipate requesting at Mount Holyoke

First Clinician's Name & Credentials:

First Clinician's Telephone Number:

Second Clinician's Name & Credentials:

Second Clinician's Telephone Number:

Upload supporting document(s)

You can upload your documentation here. Please review our Documentation Standards and Requirements to know what type(s) of documentation and information we need from you. If you do have existing documentation to share with us, we request documentation be received no less than 1 business day prior to your appointment. Please do not hesitate to contact our office with any questions about documentation.

Providing this information is voluntary. Records maintained within the Disability Services office are protected by the Family Educational Rights and Privacy Act of 1974 (FERPA).

By clicking the SUBMIT button you are verifying that the above information is accurate and that you have read and understand the confidentiality guidelines.

Disability Services engages in an interactive process to determine each student's accommodations.