Student Disclosure Form (SDF)

Student Information

This form must be filled out by the student requesting accommodations. You must have an official Northeastern ID and single sign on to complete this form. If you have not applied to/been accepted to Northeastern University, please contact our office to schedule an informational meeting. Phone: (617) 373-2675. Email: DASboston@northeastern.edu

First Name

Preferred Name

Last Name

Student ID

Northeastern Email

Please use your university issued email address

Pronouns

Phone Number

Home Campus

(i.e., Boston, Burlington, Oakland, NUin Greece, London, etc.)

Current Class Level

Disability Information

What is your diagnosis or disability?

Please list all that you are requesting services for.

Were you referred to DAS by someone?

Healthcare Provider Information

If you are under the care of a medical or mental health clinician (i.e. physician, therapist), please provide their name, specialty and approximate date of last appointment (if known).

Please describe any treatment you are currently receiving. Treatment may include therapy and/or medication.

History

While history of prior accommodations provides useful information, it does not guarantee the same accommodations will be granted at Northeastern. If you have a recent diagnosis or have not previously used accommodations, you may find it helpful to meet with a DAS disability specialist to assist you with this form.

Have you used accommodations in the past?

Have you had a psychoeducational or neuropsychological evaluation completed in the past?

If so, please attach a copy of your most recent evaluation in the final section of this form titled "Documentation Submission".

How does your disability affect you academically?

Please describe the barriers you experience to learning in and out of the classroom.

How does your disability affect any other areas of your life?

Please describe the barriers you experience in housing, dining, or social settings.

Accommodations and other resources:

The Documentation Review Committee at DAS uses an interactive process, considering information from multiple sources to understand the barriers that a student with a disability is experiencing and to determine the accommodations and other resources that will provide access for that student.

If you have suggestions for accommodations or other resources that will address the barriers you are experiencing, we invite you to share them here.

We welcome any additional information about your experience that you’d like to provide that isn’t captured in previous questions.

Documentation Submission

In addition to completing this Student Disclosure Form, please submit additional disability documentation here. Documentation may include the following: An evaluation and/or a Disability Disclosure Form completed by a qualified professional (Please see the Getting Started tab of our website) Verification of any prior accommodations including an IEP, a 504 plan, or the private school equivalent. SAT, ACT or IB accommodations and verification from other post-secondary institutions.

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