Accommodation Request Form

Student Information

Please enter your information

Welcome!

Welcome to the Office of Student Counseling, Disability, & Testing Services (SCDTS) at Northwest Mississippi Community College! Our mission is to ensure that every student has equal access to a college education by removing barriers and promoting full inclusion in all aspects of campus life.

Whether you’re beginning your college journey or continuing your academic path, our office is here to support you. We are committed to providing reasonable accommodations, individualized support, and advocacy that empower students with disabilities to achieve their educational goals.

We encourage all students who may need accommodations to contact our office early so we can work together to build a plan that supports their success. We look forward to being part of your journey.

First Name

Last Name

Middle Name

NWCC Student ID

Email

Please use your university issued email address

Please select your primary campus

Major

Phone Number

Specific Accommodation Information

Primary Eligibility Category

If selected, please indicate any "Other" diagnosis(es)

Please provide any additional specific information on your diagnosis(es):

How does your disability affect you academically?

What accommodations are you requesting?

Please specify the accommodation(s) you are requesting:

Supporting Documentation

To determine eligibility and ensure appropriate accommodations, students must submit documentation from a qualified provider. The documentation should:

• Be current (within the last 3 years);

• Be written on official letterhead and signed by a licensed medical or mental health provider;

• Include a clear diagnosis and date of diagnosis;

• Describe how the disability affects major life activities; and,

• Recommend specific accommodations with their justification.

Examples of acceptable documentation include:

• High school IEP or 504 Plan (for initial guidance; may require updated documentation)

• Psychoeducational evaluation by a licensed psychologist

• Medical documentation from a physician or specialist 5

• Audiological or vision reports

• Mental health evaluations or letters from licensed counselors/therapists

Disability Verification Form

Your medical or mental health provider can also complete the attached Disability Verification Form and either submit it directly to your Disability Services coordinator or upload it here.

Disability Verification Form

Upload supporting document(s)

Acknowledgement

I understand that some accommodations may not apply to online courses. I acknowledge that I am responsible for notifying the Disability Services Coordinator of any changes to my schedule or needs. I understand I may need to update documentation if my condition changes.

Student Certification

The information provided on this form is confidential and will be used solely for the purpose of determining eligibility for disability services in accordance with the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990.

I certify that the above information is accurate and complete to the best of my knowledge. I understand that in order to receive academic accommodations, I must provide appropriate documentation and meet with a Disability Services Coordinator.