Student Accessibility Services Consultation Request Form

Student Accessibility Services offers consultations to York students who do not have access to a family doctor and are experiencing academic difficulties and suspect that these difficulties are due to an undiagnosed attention disorder, mental health disability or learning disability. Consultations are designed to help students determine what "next steps" might be helpful to them. Our office does not provide assessments.

This form gathers information so that we can assist you in deciding "next steps" and direct you towards supports and services. It is not a diagnostic screening tool.

Students with a history of academic supports (e.g. an IEP) or who have an existing diagnosis, should register with our office. Information about registration with our office is available from the "New to our Office" page of our website: https://students.yorku.ca/accessibility/new-to-our-office

Check the box after you have read the statement below. *

Check the box after you have read the statement below. I understand the Student Accessibility Services does NOT provide diagnostic services.
Date Date / MM / DD YYYY
How hope that Student Accessibility Services can help me: *

How hope that Student Accessibility Services can help me: Information about academic supports Information about mental health and wellness supports Information about assessment options and costs Information about financial supports Information about career supports
What is your main campus? *

What is your main campus? Keele Glendon Satellite
Name Name * First Last
York Student Number *
Pronoun(s):
Email address that we can contact you at (does not have to be your York email). Please note, "HOTMAIL" accounts/messages often get flagged as junk mail and messages can be lost. *

Be sure to give us an email address that you check on a regular basis - this is how we will contact you after we receive your form.
Cell Phone Cell Phone * - ### - ### ####
Can we leave messages at this number? *

Can we leave messages at this number? Yes No
Are you currently receiving OSAP? *

Are you currently receiving OSAP? Yes No
Are you currently enrolled in classes? *

Are you currently enrolled in classes? Yes No
How many credits have you completed toward your degree? *
How many credits do you customarily complete each year? *
Do you have a family doctor? *

Do you have a family doctor? Yes No
Have you spoken with your family doctor (or other health care professional) about the difficulties you are experiencing? Have they have provided a diagnosis and/or treatment?

Students with existing diagnosis should explore registration with our office. If you are already registered with Student Accessibility Services, please make an appointment with your Accessibility Counsellor to discuss your difficulties.
What academic difficulties are you experiencing? *
Are these difficulties recent or since childhood? *
How have you tried to address your difficulties? *
Have you done poorly in any courses at York (or another post-secondary institution)? *

Have you done poorly in any courses at York (or another post-secondary institution)? Yes No
Have you ever failed a course because you did not complete or submit assignments?

Have you ever failed a course because you did not complete or submit assignments? Yes No
How would you rate your learning skills (e.g. time management, prepping for exams, notetaking)? *

How would you rate your learning skills (e.g. time management, prepping for exams, notetaking)? Poor Average Good
Are you able to complete tests and exams in the time given to you in class? If NO, please describe the difficulties you are experiencing. *
Did you have any academic difficulties or receive extra assistance in elementary or high school? If YES, please provide details. *
Have you ever had difficulties with the following? Please check all that apply.

Have you ever had difficulties with the following? Please check all that apply. Hearing Vision Sleep Migraines Mental health Attention/concentration Heath Concerns Drug or alcohol abuse Other Other
If yes, please share how your learning was impacted:
Are you having any difficulties with stress, anxiety, depression or other emotional/psychological concerns? *

Are you having any difficulties with stress, anxiety, depression or other emotional/psychological concerns? Yes No I'm not sure
If you answered yes, please elaborate:
Did you have trouble learning to read, spell or do math? *

Did you have trouble learning to read, spell or do math? Yes No I don't know
Did you have difficulties with short attention span, concentration or restlessness as a child? *

Did you have difficulties with short attention span, concentration or restlessness as a child? Yes No I don't know
Do you experience any of the following? Please check all that apply. *

Do you experience any of the following? Please check all that apply. Lack of motivation Low energy Difficulties attending lectures Difficulties paying attention during lectures Feeling nervous, restless or tense Meeting deadlines None of the above
Have you accessed any of the supports listed below? Please check all that apply. *

Have you accessed any of the supports listed below? Please check all that apply. Medication Counselling Assistive Technology (e.g. reading software, recording tools) Tutoring or extra help in school None of the above
Have you ever completed a formal assessment of your needs (e.g. reading, speech)? Does anyone in your family have learning difficulties? If so, have they been diagnosed with a disability? *
Who referred you to our office? (e.g. self or other) *
We are meeting with students via Zoom (you are welcome to dial into the meeting or leave your camera off). We have appointments available Mondays, Wednesdays and Thursdays between 9:30am and 12pm and 1pm and 3pm. Please indicate your availability during these times. *
Notification of How Your Information will Be Used

Student Accessibility Services collects medical documentation and other information pertaining to your functional limitations, your history of learning or personal circumstances for the following purposes:

• To verify the need for disability related accommodations for academic work and
• To develop and implement effective disability related accommodations and supports

Student Accessibility Services respects your privacy and keeps your information confidential. Information may be shared with university staff, but only on a need-to-know basis to allow them to perform their duties and to provide academic or other disability related accommodations on campus.

Examples:
• Test and Exam accommodations will be shared with the Alternate Exam/Test Scheduling for invigilation.
• The name of students with a reduced course load as an accommodation may be shared for fees adjustment purposes or to arrange bursaries.
• Accessibility Counsellors may speak to a professor, registrar or residence staff to arrange accommodations and supports.
• When a student encounters difficulties that require attention from other University units, such as Student Counselling & Development, Students of Concern Committee, Office of Student Community Relations, Residence Life, necessary information is shared with those units.

To protect your information, all university staff receiving information follows University policies and guidelines, the Freedom of Information and Protection of Privacy Act and other legal requirements*.

"Frequently Asked Questions (FAQs) About How Information is Used" is available from our website: https://accessibility.students.yorku.ca/index.php/how-your-information-is-used

If you have any questions, please send an email to sasreg@yorku.ca. Your email will be forwarded to the Director for follow up as soon as possible.

* Student Accessibility Services provides academic accommodation and support to students with disabilities in accordance with the Ontario Human Rights Commission’s Policy on accessible education for students with disabilities and York University Senate Policy on Academic Accommodation for Students with Disabilities.

Student Accessibility Services at York University is subject to the Freedom of Information and Protection of Privacy Act ("FIPPA") and York University’s Policy on Access to Information and Protection of Privacy. Information is collected under the authority of The York University Act, 1965 to administer the university-student relationship.
*

I have read and understand the "Notification of How Your Information Will Be Used".