Documentation of a Psychological Disability
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1 Documentation of a Psychological Disability Student's First Name: Student's Last Name: Today's Date: Date of Diagnosis : Date Student was Last Seen: Frequency of Appointments: Once a week Twice a week Once a month Once every six months Once a year On an as needed basis DSM-IV Diagnosis Please feel free to use DSM-V categories if that is how you diagnosed the student. Axis I Axis II
2 Axis III Axis IV Axis V (GAF) Score: Present time: Average over last year What is the expected duration of the condition? In addition to DSM-IV criteria, how did you arrive at your diagnosis? Please Check all relevant items: Short term (Less than 6 months) Episodic Long Term (6 months-1 year) Chronic (longer than 1 year with frequent recurrence) Structured or unstructured interviews with the person him/herself Interviews with other persons Behavioral Observations Developmental History Educational History Medical History Neuropsychological Testing Psychoeducational Testing Standardized or unstandardized rating scales
3 If you selected Neuropsyc hological, please provide the date of the testing If you selected Psychoeducational testing, please provide the date of the testing Is the student currently taking any medication? Yes No If yes above, please provide information on each medication below: Medication/Dosage/ Frequency (e.g., Celebrex 200 mg 1x daily)
4 Without Medication/Mitigation No Impact Moderate Impact Substantial Impact Don't Know Concentration Memory Sleep/Waking Eating Social Interaction Self-Care Managing Internal Distractions Managing External Distractions Complex/Abstract thinking Attending class regularly and on time Making and keeping appointments Stress Management Organization and Prioritization of task
5 With Medication/Mitigation No Impact Moderate Impact Substantial Impact Don't Know Concentration Memory Sleep/ Waking Eating Social Interaction Self-Care Managing Internal Distractions Managing External Distractions Complex/ Abstract Thinking Attending Class regularly and on time Making and Keeping Appointments Stress Management Organization and Prioritization of Tasks
6 Please list the student's current symptoms. Then indicate what reasonable academic accommodations would be related to the symptom indicated. More detailed information regarding reasonable academic accommodations can be found at: reasonable accommodations. Example: Symptom "Due to the student's depression, the student has difficulty concentrating." Recommended Accommodation: Due to the difficulty concentrating, the student will require extra time on tests. Symptom 1: Recommended Reasonable Accommodation: Symptom 2: Recommended Reasonable Accommodation: Symptom 3: Recommended Reasonable Accommodation: What is the student's prognosis? How long do you anticipate that the student's academic achievement will be impacted by his/her disability? Please select one option 6 months 1 year More than 1 year
7 Is there anything else you think we should know about the student's psychological disability?
8 Role of the person completing this form (check all that apply) Treating Professional Psychotherapy Medication Supervision Treating Professional Evaluator 2 nd Opinion Evaluator Please enter your Full Name License Number Profession Provider's Address Provider's Phone # Fax # Provider's Address
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