School Accommodation Request | EKM Psychiatry

ABOUT YOU

First name

Last name

Birthday

Month

Day

Year

Email address

Phone number

School or University Name

Disability Services Contact Name (if known)

Disability services email or fax

Type of request

Accommodations needed

Be as specific as possible - this helps your provider write the most useful letter.

Specific language or instructions required

Submission deadline (if applicable)

Rush processing needed?

Attach School Form in PDF Format (if applicable)

Additional Notes (Optional)

PATIENT ACKNOWLEDGMENT

I am an active patient at EKM Psychiatry with an established treatment history at this practice.

I understand that submission does not guarantee the letter will be provided or that my accommodations will be approved by my school.

I understand a fee is due prior to work beginning and is non-refundable once the letter has been drafted.

I understand EKM Psychiatry can only certify what is supported by my clinical record and cannot exaggerate symptoms or impairment.

I have read and agree to EKM Psychiatry's documentation request policy.

Signature

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Date

Month

Day

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