Disability Certification Intake Form

The Office of Student Affairs coordinates services for students with permanent and temporary disabilities such as but not limited to cognitive learning disabilities/ADD/ADHD; dyslexia; mobility, visual and hearing impairments; chronic medical conditions; psychiatric disabilities; and substance abuse/recovery with the goal of addressing the individual disability needs of students while upholding the academic integrity and standards of Union.

If you are a new or returning student with a disability and have not registered with the Office of Student Affairs to receive Disability Services, you should REGISTER NOW! Just start by completing the Disability Services Intake Form below.

Once you fill out the Disability Services Intake Form, you will be contacted by the Office of Student Affairs to set up an appointment with the Assistant DIrector of Accessibility Services, Sonali Prabhakar. Sonali will work closely with you to learn what functional limitations you are experiencing and what accommodations you may need.

In the meantime, please complete the Disability Release Form which allows us to receive your medical records and contact your medical provider, if necessary. Then, the Office of Student Affairs will provide you with a Disability Certification Form for your provider to complete. This form requests more detailed information about your disability and functional limitations and includes specific instructions for your provider. Please note that the licensed or otherwise properly credentialed health professional must have undergone appropriate and comprehensive training, have relevant experience, and have no personal relationship with you. Please note that your meeting with Dean Asgaralli is not dependent on prior receipt of your medical documentation, and can happen as soon as you register for services.

The information we gather at the interview and any additional documentation from your provider will allow us to have as much information as possible to determine appropriate accommodations. Once the forms are complete, please mail or submit them with any additional supporting medical documentation to the attention of the following:

Sonali Prabhakar

Assistant Director of Accessibility Services

Union Theological Seminary

3041 Broadway, NY, NY 10027

You may also have the completed forms scanned and emailed to sprabhakar@uts.columbia.edu

For more information on Disability Services at Union, view: www.utsnyc.edu/disability.

The Office of Student Affairs looks forward to supporting you throughout your theological journey.

Disability Services Registration Form

I submit this form with the Office of Student Affairs at Union Theological Seminary to begin the intake process for disability services which includes appropriate accommodations and academic adjustments to ensure that I have an equal opportunity to attain the same quality of education as well as can be assessed for course content and evaluated in the same manner as students without disabilities.

Name*

First Name

Last Name

Date/Time*

Please list the current challenges you face.*

Please list the academic accommodations you seek.*

Signature*

[clear]

Use your mouse or finger to draw your signature above

Disability Services Release Form

I permit the Office of Student Affairs to receive my medical records to keep on file in the Office of Student Affairs and to contact my medical provider to discuss my disability for a proper determination of necessary accommodations.

Student Name*

First Name

Last Name

Union email address*

@utsnyc.edu

Provider Name*

Provider Phone*

Provider Email*

Student Signature*

[clear]

Use your mouse or finger to draw your signature above

Date/Time*

Additional Information

In the comments section below, please provide any additional information you feel is important. Feedback regarding this form is also welcome. If you already have documentation to verify your disability and accommodation needs on letterhead from your provider, you may upload it here.

Comments

Supporting Documentation From a Medical Provider

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