Printed on Office of Disability Services Letterhead
| ODS Counseling/Primary
Care Health Service Referral Form CONFIDENTIAL I, _________________, give permission for the Office of Disability Services (ODS) to notify Counseling Service/Primary Care Health Service re: my disability diagnosis____________________ and that as of___________ I have registered for support services with ODS for the fall/spring semester. Student signature _________________ ODS signature ___________________
ODS 8/09 17 |