Public Accommodation Request

* indicates a required field

Student Information

Current Student Status at CSUEB(Required) *

Please provide your university issued email address. If you do not have an university email, provide your personal email.
Reason for contacting Accessibility Services(Required) *

Accommodations needed during appointment(Required) *
Please let us know if you will require any accommodations during your appointment

If you would like to share any relevant documents with Accessibility Services, please upload them.
Do you have any disability paperwork?(Required) *


Please provide three available dates and times, between the hours of 8:30am-3pm (Monday-Thursday), to schedule an appointment with an counselor.
During COVID-19, we are working remotely. Please let us know if you would prefer a phone or video meeting.(Required) *