Wellesley College’s Disability Services Providers are interested in preparing for your arrival and in making your transition to campus as smooth as possible. Please complete/return this form with any relevant documentation if you are requesting accommodations based on a disability or would like to introduce yourself. If you would like to speak to someone about Disability Services, feel free to call one of the staff members listed on the back of this form. We understand this may be new to you and encourage you to meet with a staff member when you arrive. These staff will review your materials and respond to your request confidentially. To give us proper time to prepare, we ask that you respond by June 10. Late materials may not be responded to in time to provide the accommodations.

Send this form with your documentation to: Jim Wice, Director of Disability Services, Wellesley College, 106 Central Street, Wellesley, MA 02481. Make inquiries at (781) 283-2434 or jwice@wellesley.edu.

Name____________________________Signature_____________________________________

Address_______________________________________________________________________

Phone __________________________ Email______________________Date_______________

1. Please check off any disabilities you have and include what the specific disability is. Attach documentation.

_____Learning Disability/ADD _____Emotional/Psychiatric Disability _____Mobility

_____Blind or Low Vision _____Deaf or Hard of Hearing _____Health Issues

_____Other

State the specific disability or disabilities_____________________________________________

2. Please describe any limitations you have that are associated with your disability or disabilities. Feel free to use the reverse side or attach a page for this or other responses.

______________________________________________________________________________

3. Please specify any disability related accommodations you are requesting. Disability appropriate documentation is required for an accommodation (see reverse side). Staff can assist prior to your arrival if preparation activities are needed such as in the 1^st four items below.

Check Off Specific Request

_____Alternative Print Media (reading onto tape, large print, Braille)___________________________

_____Classroom Accommodations _____________________________________________________

_____Housing (physical accessibility, medical singles) _____________________________________

_____Sign Language Interpreters_______________________________________________________

_____Testing Accommodations _________________________________________________________

_____Other including general information__________________________________________________

-------------------------------------------------------------For Office Use Only------------------------------------------------------

Received by_______________________Date Received___________________Action Taken__________________

Please feel free to contact the Disability Service Providers listed below with any questions or to introduce your self.

Students with Learning Disabilities, Attention Deficit Disorder and Physical Disabilities

Jim Wice, Director of Disability Services, (781) 283-2434

Students with Medical Disabilities

Vanessa Britto, Director of Health Services, (781) 283-2810

Students with Psychiatric Disabilities

Robin Cook-Nobles, Director of Counseling Services, (781) 283-2839

Documentation Types

All medical and psychological documentation should be submitted on the doctor's letterhead and should include the diagnosis, prognosis, and any limitations especially as they relate to the accommodations requested. The doctor or medical professional should clearly explain why an accommodation is needed based on your disability and not just make a statement without supporting it. You're documenting professional should also sign and date the letter and include how long s/he has treated you.

For documentation of learning disabilities and attention deficit disorders a current neuropsychological evaluation is needed. Though IEP’s, 504 plans, and other educational plans are helpful, an neuropsychological evaluation is necessary to determine what academic accommodations are needed.

For documentation of psychological disabilities a psychologist or psychiatrist should include a current DSM diagnosis along with the other items described in the first paragraph here.

For documentation of deafness or hard of hearing a current audiologists report and letter would be appropriate.

For documentation of blindness or low vision a current ophthalmologists report and letter would be appropriate.

For documentation of mobility impairments a current assessment from an orthopedist, neurologists, or other medical doctors knowledgeable of the particular disability would be appropriate.

Please feel free to contact Jim Wice, Director of Disability Services, with any questions on what might be considered appropriate documentation of a disability.

General Inquiries

Students are welcome to make general inquiries about disability resources, organizations, or anything else regardless of whether or not they need accommodations. Feel free to contact Jim Wice to get acquainted with information about disability resources on and off campus or just to introduce yourself. You can do this by completing this form and or by calling or e-mailing him directly.