Verification Form for Housing Accommodations

In order to determine reasonable accommodations for housing, Angelo State University requires current and comprehensive documentation of the student’s condition from a licensed clinical professional or health care provider.

This form must be completed by a licensed clinical professional or health care provider familiar with the history and functional limitations of the student’s condition(s). The provider may also attach a report providing additional related information.

Common accommodations for health issues such as allergies, or diabetes will not require submission of this form. Please make sure to note requests for these types of diagnoses on your housing application.

All fields marked with asterisk (*) are required.

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Health Care Provider Name and Title:*

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State of License and License Number:*

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Address:*

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Phone:*

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Student Name:*

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Date of initial contact with student:*

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Date of last office visit with student:*

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Diagnosis:*

Please list all the relevant diagnoses.

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Approximate onset date of diagnosis:*

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Severity of Symptoms:*

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Prognosis of Disorder:*

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Describe the symptoms related to the student's condition that cause significant impairment in a major life activity.*

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Please state the specific recommendation regarding housing, and a rationale as to why these housing needs are warranted based upon the student’s disability. Indicate why the change(s) to the housing environment you recommend are necessary.*

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Additional related information:

(50 MB max)

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Acknowledgement:*

I certify that I conducted or formally supervised and co-signed the diagnostic assessment of the student named above. I have determined the accommodation(s) requested is/are necessary to afford the individual an equal opportunity to use and enjoy on-campus living. I certify there is an identifiable relationship between the disability and the accommodation requested. I agree to verify the information contained herein should I be contacted by the ASU Student Disability Services Office.

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