great minds think differently - tulane university · 2018-01-10 · great minds think differently...

6823 St. Charles Avenue Ph: 504.862.8433 Science & Engineering Lab Complex Fx: 504.862.8435 Building 14, Suite 103 [email protected] New Orleans, LA 70118 www.accessibility.tulane.edu Great Minds Think Differently Goldman Center for Student Accessibility Provider Form In order to help determine reasonable accommodations, qualified professionals may submit documentation on behalf of students to provide the Goldman Center with additional information. This information will be used in conjunction with the student’s self-report, the Goldman Center staff member’s structured interview, and the essential elements and design of the classroom/dining/residential environment to determine reasonable accommodations on an individual basis. Please note that the information provided within this document will be considered holistically with all other information gathered. Specific information provided within will neither guarantee the student will receive a specific accommodation nor prevent the student from receiving a specific accommodation. All information provided will be confidentially used by Goldman Center staff to reach an eligibility determination. It is not mandated that students use this form, but it can aid treatment providers in supporting reasonable accommodation requests. Student’s Name: Diagnosis/es and date diagnosed: Brief synopsis of treatment and date last seen (ex: duration, frequency, nature of): Impact of diagnoses on functioning: Specific recommendation(s) for accommodation(s): Name and Credentials of Provider:_____________________________________________________________ License number:______________________________________Telephone:_____________________________ Signature:______________________________________________ Date: _______/_______/______________

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6823St.CharlesAvenue Ph:504.862.8433Science&EngineeringLabComplex Fx:504.862.8435Building14,Suite103 [email protected],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:_______/_______/______________

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