Psychological/Mental Health Need Special Housing
You may request special housing if you have a qualified psychological/mental health condition. Housing & Residence Life works in conjunction with Furman’s Counseling Center and our on-campus medical professionals to ensure consistency in evaluating special housing requests. Only completed requests are reviewed. A completed request consists of this form, the
Information from Health Care Provider (Psychological/Mental Health form
, and the
Authorization for Release of Information form
A diagnosis must be made by a licensed mental health professional, such as a clinical social worker, a professional counselor, a psychologist, a psychiatrist, or a neurologist. Documentation must include the professional’s license number.
The mental health care provider must not have significant personal ties to the student or the student’s relatives beyond the professional relationship.
Requests and/or statements included in the medical documentation should not be interpreted as automatic approval for special housing
STUDENTS: February 23, 2015
STUDENTS FALL 2015: June 5, 2015
INFORMATION TO BE COMPLETED BY STUDENT:
Date of Request:
When Accommodation is Needed:
2015-2016 Academic Year
Furman Email Address:
Date of Birth:
Furman Student ID Number:
In the space below, please detail your request, to include the type of housing, and the reason(s) for it:
NOTIFICATION OF APPROVAL/DENIAL WILL BE SENT TO THE STUDENT’S FURMAN UNIVERSITY E-MAIL ADDRESS. PLEASE MONITOR THAT E-MAIL FOR RESPONSE AND/OR REQUESTS FOR ADDITIONAL INFORMATION.
Do Not Fill This Out