Printed on Office of Disability Services Letterhead

 

Counseling/Health Services Referral Form
CONFIDENTIAL

I, _________________, give permission for the Office of Disability Services (ODS) to notify Counseling Services/Health Services re: my disability diagnosis____________________ and that as of___________ I have registered for support services with ODS for the fall/spring semester.

Student signature _________________
Date ___________

ODS signature ___________________
Date ___________ 

 

ODS 8/08

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