Public Accommodation Request

* indicates a required field

Accommodation Request Form

Please Note
All of the information you provide below is provided on a voluntary basis. This information will be kept confidential and serves as a request for services only. If no services are being provided, this information will be kept on file for a period of five years from the last date of attendance.
How would you like us to refer to you when we are not using your name? (For example: she/her/hers, they/them/theirs, etc.)
If you are a student and do not have a student ID, please contact us at (618) 650-3726
Please use your university issued email address
Were you referred to our office?Required

Specific Accommodation Information

If you are an employee, how does your diagnosis affect you in the workplace?
Do you use a wheelchair?Required
Do you need vision related accommodations?
Do you need deaf/hard of hearing accommodations?
Do you currently take medications related to this request?
Are you receiving assistance from any of these providers?
Please check all that apply.

If not listed above, what other service provider are you receiving services from?
Upload supporting document(s)

Please upload any documentation you have related to your diagnosis. You can find more information about documentation on our website.