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Instructions for Completing the Verification of Need for

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Instructions for Completing the Verification of Need
for Accessibility Services form
Please read these instructions carefully.
Some information that students and their providers include here is usable for multiple types of
accommodations, such as academic accommodations and residence life accommodations.
Some accommodations will also have their own, specific information requests.
Please read over all of the pages carefully if you are requesting multiple types of accommodations.
This form has three portions:
• Pages 1-2: To be completed by the student,
• Pages 3-5: To be completed by one or more medical, psychological, and/or educational
professional(s) to verify the information provided by the student on pages 1-2 (You may submit
multiple copies, completed by different providers, if necessary.), and
• Pages 6-10: To be completed by one or more medical, psychological, and/or educational
professional(s) if you are making one of the following types of requests:
o Support Form A: Support for Parking Pass Request – page 6
o Support Form B: Support for Emotional Support Animal Request – page 7
o Support Form C: Support for Single Room Assignment Request – page 8
o Support Form D: Support for Release from Housing Contract Request – page 9
The student should print their name at the top of each page.
Students who do not have access to professional documentation but who have academic accessibility
needs should schedule an appointment to discuss their individual situations and next steps. Please
email Stephanie Edgar sedgar@mx.lakeforest for such an appointment.
PLEASE NOTE: Not every condition meets the threshold of being a disability at the college level.
Last update: 1 April 2019
Verification of Need for Accessibility Services
Part 1: To be completed by the student – This portion must be completed for all requests
Student Name:
Pronouns:
she/her/hers
they/them/theirs
Other:
I am (please check one):
A current Lake Forest College student
An incoming new or transfer student
I am requesting these accommodations (please check all that apply):
Parking
Permit
Residence Life (includes: air conditioning, single room, release
from housing contract, meal plan exemption
1
, bathroom
proximity, and emotional support animal
2
)
I request the following information from my health and/or educational professional be used as verification of my need for
accessibility services. I understand this and other verification/documentation may be reviewed and discussed with members
of the Accessibility Services Consultation Team as appropriate. I understand that a member of the Accessibility Services
Consultation Team may contact me for further information and/or to discuss options related to my request(s). Furthermore,
I give my consent for the appropriate clinician or professional, acting on behalf of Lake Forest College, to contact the
professional(s) completing this form for additional information as needed.
Student Signature:
Date:
E-mail Address:
Phone:
1
Exemptions from the meal plan are only granted when there are documented restrictions that our campus dining
service is unable to accommodate.
2
Emotional support animals (ESAs) and service animals are different. ESAs are allowed only in a student’s
residence hall room and must be approved through this process before they will be allowed on campus. Additional
documentation and animal registration is required for both ESAs and service animals.
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signature
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Student Name:
Verification of Need for Accessibility Services form
2
Part 1: To be completed by the student
1. Please describe the disability(ies)/condition(s) for which you are providing verification.
2. If you have received accommodations in the past, what has proven most successful for you? Why?
3. For Residence Life accommodation requests: What accommodation(s) are you requesting?
I am requesting (please check all that apply):
Single
room
Emotional
support
animal
Air-
conditioning
Meal plan
exemption
Release
from
housing
contract
Other:
Student Name:
Verification of Need for Accessibility Services form
3
Part 2: To be completed by the health care and/or educational professional
The student should ask a professional (medical, mental health, educational) who is familiar with the
student’s disability and accommodation requests to complete Part 2. The professional completing this
form may not be related to the student, and we do not accept personal notes from health care
providers.
If the person completing this section is not the diagnosing professional, please attach a copy of the
original diagnostic report. If that information is contained within an IEP or 504 Plan, please attach those
documents. Documents that address these questions can be submitted in place of pages 3-5.
The student’s disability/diagnosis is:
The disability/diagnosis was determined according to criteria/symptoms from:
DSM-IV
DSM-V
Medical diagnostic criteria
Other:
The student meets these criteria/symptoms:
Methodology used:
Interview
Diagnostic assessments:
Other:
Student Name:
Verification of Need for Accessibility Services form
4
This student’s disability creates barriers to the following activities:
Walking
Hearing
Seeing
Breathing
Speaking
Reading
Writing
Learning
Processing
Memory
Executive
information
functioning
Physical health:
Other:
What recommendations do you have for accommodations that could ameliorate the barriers created
by the student’s disability?
Academic
Extended test time (1.5x)
OR
Extended test time (2.0x)
Distraction-reduced testing environment
Note-taking assistance/peer notes
Assistive technology
Audiobooks/electronic texts
Other:
Residence Life
Single room
Bathroom proximity
Emotional support animal
Air-conditioning
Meal plan exemption
Release from housing contract
Other:
Additional recommendations
Parking pass
Other:
Student Name:
Verification of Need for Accessibility Services form
5
Additional information about this student relevant to the request(s)
Please see the following pages for additional information related to the following requests:
• Support Form A: Support for Parking Pass Request – page 6
• Support Form B: Support for Emotional Support Animal Request – page 7
• Support Form C: Support for Single Room Assignment Request – page 8
• Support Form D: Support for Release from Housing Contract Request – page 9
Print Name:
Title:
Phone:
Email:
Signature:
Date:
Send to (via fax, email, or postal mail):
Accessibility
Mail Stop: H & W
555 N. Sheridan Rd
Lake Forest, IL 60045
fax: 847-735-6098
Email: healthandwellness@lakeforest.edu
Provider’s Clinic Stamp or License
Number, or attach business card here:
click to sign
signature
click to edit
Student Name:
Verification of Need for Accessibility Services form
6
Support Form A: Support for Parking Pass Request
When considering a student for a parking pass through the Accessibility Services process, we request
that the information from a student’s provider answer the questions below.
PLEASE NOTE: Approved requests usually require weekly visits that are at least 10 miles away from the
College and that are not accessible by public transportation. Requests for monthly doctor’s
appointments or prescription pick-up are usually not supported.
Frequency of appointments (weekly, biweekly, etc.),
Estimated duration of appointments (3 months, academic year, indefinitely, etc.), and
Address of the location where the appointments will take place.
I am the provider who completed pages 3-5 of this form.
If you are not the provider who completed pages 3-5 of this form, please provide your information on
page 10.
Student Name:
Verification of Need for Accessibility Services form
7
Support Form B: Support for Emotional Support Animal Request
When requesting an emotional support animal as an accommodation, we use the American
Psychological Association’s guidelines on what appropriate documentation should include. This portion
of the student’s Verification form should be completed by a mental health practitioner.
The student should have a DSM-IV or DSM-V diagnosis listed on page 4.
PLEASE NOTE: Requests that do not meet all of these criteria may not be considered.
How does the animal help alleviate the condition and contribute to the student’s treatment?
How do the student and animal interact, and for how long have you observed them?
What are the possible negative effects to the student if they do not have the animal with them?
Has the animal received training from a qualified trainer, and if so, what training has it received?
I am the provider who completed pages 3-5 of this form.
If you are not the provider who completed pages 3-5 of this form, please provide your information on
page 10.
Student Name:
Verification of Need for Accessibility Services form
8
Support Form C: Support for Single Room Assignment Request
When considering a single room as a housing accommodation, there is no one set of information
necessary for determination. A student’s Verification form and interview should make the case as to
why no other living arrangement in our residence halls can meet the student’s needs. Approved
students’ requests are contingent on the availability of a room that will meet the student’s need, which
may not be immediately available.
Single room accommodations could be approved in situations like:
• a student with severe anxiety and obsessive-compulsive disorder, who needs control over the
environment;
• a student on the autism spectrum who needs an environment in which they can control stimuli
and decompress from the daily overstimulation being in the college environment creates;
and/or
• a student with severe and frequent migraine headaches, who needs to control the residence hall
room environment (temperature, light, etc.).
Why do you support this student’s request for a single room?
I am the provider who completed pages 3-5 of this form.
If you are not the provider who completed pages 3-5 of this form, please provide your information on
page 10.
Student Name:
Verification of Need for Accessibility Services form
9
Support Form D: Support for Release from Housing Contract Request
In most cases, a student’s disability can be accommodated within our residence halls. If Residence Life
can meet a student’s accommodation needs, the request for a release from the housing contract will be
denied.
When considering the release from a housing contract as an accessibility request, there is no one set of
information necessary for determination. A student’s Verification form and interview should make the
case as to why no living arrangement in our residence halls can meet the student’s needs, which may
include a room type the student has not yet tried, such as a single room and/or a room with air
conditioning.
Here are a few examples of requests for release from the housing contract that would not be
immediately approved:
• A student who needs strict control of the environment in which they live but who has not tried
living in a building with air conditioning and/or a single room, and/or
• A student who makes a request based on severe anxiety but who has never tried living in a
single room.
In these situations, the student may be offered an alternative accommodation, rather than the release
from the housing contract.
Why do you support releasing this student from their housing contract?
I am the provider who completed pages 3-5 of this form.
If you are not the provider who completed pages 3-5 of this form, please provide your information on
page 10.
Student Name:
Verification of Need for Accessibility Services form
10
To be completed by the health care and/or educational professional
I have completed the following support forms for the student named above:
Support Form A: Support for Parking Pass Request – page 6
Support Form B: Support for Emotional Support Animal Request – page 7
Support Form C: Support for Single Room Assignment Request – page 8
Support Form D: Support for Release from Housing Contract Request – page 9
Print Name:
Title:
Phone:
Email:
Signature:
Date:
Send to (via fax, email, or postal mail):
Accessibility
Mail Stop: H & W
555 N. Sheridan Rd
Lake Forest, IL 60045
fax: 847-735-6098
Email: healthandwellness@lakeforest.edu
Provider’s Clinic Stamp or License
Number, or attach business card here:
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Completed 22 August 2020

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