Goucher College
Health and Counseling Services
2016-2017 Request for Special Housing Accommodations
The following guidelines have been established to accommodate students who have a special need or disability that may
impact their housing.
Policy Statement: The Office of Residential Life is committed to ensuring that, to the extent possible, our housing
facilities, programs and services are available to ALL students. Reasonable accommodations are available to meet the
special needs of eligible students. All requests will be reviewed on a case-by-case basis and documentation of a special
need or disability does not guarantee that your application will be approved. Assignments are made only if space is
available. Assignment to a specific residence hall cannot be guaranteed.
Procedure:
1. Complete this form and submit it to Health and Counseling Services.
2. Request your healthcare provider to provide documentation in support of your request using the attached
Healthcare Provider Form. “Healthcare provider” means a licensed healthcare provider (e.g. MD, DO,
Psychologist, Licensed Clinical Social Worker, Nurse Practitioner, etc.).
3. If special housing accommodations are for academic needs, paperwork will be forwarded to Dr. Frona Brown,
College Disabilities Specialist.
4. Students must re-apply each year and submit updated supporting documentation as necessary.
If you have any questions or concerns regarding this policy, please contact Health and Counseling Services, at 410-3376050.
Please complete the information below and submit this form with the Healthcare Provider form to Health and
Counseling Services by mailing or faxing to the address below:
Name: ________________________________________ College ID #:
Campus Address:
Cell Phone:
Home Address: _____________________________________________________________________________________
Please state clearly the residence hall accommodations that you are seeking (e.g., single room, lower floor, handicap
accessible, substance-free) and the reasons for your request (use reverse side, if necessary): By my signature, I give my
consent for Goucher College to contact my healthcare provider for additional information as needed and give my
consent for Health and Counseling Services to communicate my needs with the Office of Residential Life.
(Student signature)
Submit this form to:
Health and Counseling Services
Goucher College, Heubeck Hall
1021 Dulaney Valley Road
Baltimore, MD 21204
TO HAVE YOUR APPLICATION REVIEWED AND A MEDICAL PLACEMENT MADE PRIOR TO ROOM DRAW
YOUR APPLICATION MUST BE SUBMITTED BY THE FOLLOWING DEADLINES:
The deadline for the 2016/2017 school year for current students is April 1st, 2016.
The deadline for the 2016/2017 school year for incoming students is June 15th, 2016.
ANY APPLICATIONS RECEIVED AFTER THIS DATE WILL BE CONSIDERED ON A SPACE AVAILABLE BASIS.
Goucher College
Health and Counseling Services
410-337-6050
410-337-6051 (fax; please use a confidential cover sheet if submitting by fax)
Healthcare Provider Form
Student Name:
Submit the following form to your healthcare provider. “Healthcare provider” means licensed healthcare provider (e.g.,
e.g. MD, DO, Psychologist, Licensed Clinical Social Worker, etc.). This information should not be provided by an
immediate family member.
Healthcare Provider Name:
Phone Number:
_____________
Healthcare Provider Signature:
Date:
______
Professional License Number/State:
Email:
______
Please provide the following information regarding the above-named student’s request for housing accommodations at
Goucher College. It should be forwarded on your letterhead to the office listed below, along with this form.







The student’s diagnosis/disability/special need requiring housing accommodation.
Date of most recent assessment.
The current functional impact of (or limitations imposed by) the condition, and the degree of impact (e.g., mild,
moderate, severe).
The expected duration of the condition.
The recommended housing arrangement or accommodation.
A description of how the accommodation will enhance the student’s ability to fully use and enjoy college-owned and
administered housing and/or mitigate the functional impact of the student’s condition.
The level of need for the requested accommodations (e.g., preferred, versus medically necessary) and any negative
impact that might result if accommodations are not provided.
Submit to:
Health and Counseling Services
Goucher College, Heubeck Hall
1021 Dulaney Valley Road
Baltimore, MD 21204
410-337-6050
410-337-6051 (fax; please use a confidential cover sheet if submitting by fax)
TO HAVE YOUR APPLICATION REVIEWED AND A MEDICAL PLACEMENT MADE PRIOR TO ROOM DRAW
YOUR APPLICATION MUST BE SUBMITTED BY THE FOLLOWING DEADLINES:
The deadline for the 2016/2017 school year for current students is April 1st, 2016.
The deadline for the 2016/2017 school year for incoming students is June 15th, 2016.
ANY APPLICATIONS RECEIVED AFTER THIS DATE WILL BE CONSIDERED ON A SPACE AVAILABLE BASIS.