AAA Consult Questionnaire | Remothering You

Academic Accommodation Assessment

Consultation Questionnaire

We're glad you're here. These questions help us begin to learn what kind of support may make your learning experience more accessible. We'll review your responses and be in touch within 24 business hours to schedule your assessment.

Legal First Name (for records/insurance)

Legal Last Name (for records/insurance)

If you go by a name that's different from your legal name, please share it here so we can address you correctly.

What university do you attend?

Are you an undergraduate or graduate student?

Undergraduate

Graduate

Do you live on campus or off campus?

On campus

Off campus

Street Address

Apt./Unit #

City

State

Zip Code

Phone

Birthday

Month

Day

Year

What's been feeling most emotionally or mentally difficult for you lately?

How have these experiences been affecting your coursework or ability to focus, learn, or keep up academically?

What has your campus and social life been like while navigating these challenges?

Have you ever been diagnosed with a mental health condition?

Yes

If yes, what mental health condition(s) have you been diagnosed with, when, and by whom?

Please include the diagnosing provider's name, the clinic or organization, if applicable, and the city and state where you were diagnosed.

Are you currently receiving mental health therapy?

Yes, I'm currently in therapy

If yes, please provide your therapist's name, the clinic or organization, if applicable, and the city and state where they provide services.

Do you currently take any prescription psychotropic medications?

Yes

If yes, please list your current medications and the name, clinic or organization, and location (city/state) of your prescribing provider.

Over the past year, have you had thoughts of suicide or taken steps to harm yourself or end your life?

Yes

A "yes" response won't affect your access to an assessment. It helps us understand what's been happening for you lately so your evaluation fully reflects your experiences.

If yes, please tell us a bit more about when that was, what was happening for you around that time, and how you're doing now.

Have you been discharged from a psychiatric hospital or inpatient program in the past 12 months?

Yes

If yes, please share the facility name and your approximate admission or program start date.

We appreciate you being so open. Those questions can feel personal and raw. The rest of this form is simple logistics: context about payment and a few quick questions to help us schedule your assessment.

The fee for an Academic Accommodation Assessment (AAA) is $800, which includes the evaluation, a comprehensive report tailored to your university's requirements, and collaboration (with your permission) with current and previous providers and any loved ones you identify who can offer helpful perspectives, such as professors, friends, or partners.

Although AAAs are not covered by insurance, some universities offer stipends to cover the cost; please check with your university to find out if any options are available.

Which day(s) do you have the most flexibility to meet for your assessment?

This helps us explore which of our available appointments might work best for you. We'll reach out via email with a few options so you can select the one that best fits your schedule.

Do you prefer a certain time of day?

Morning

Afternoon

Evening

Flexible