COMMUNITY COLLEGE OF ALLEGHENY COUNTY
Supportive Services Supportive Services Supportive Services Supportive Services
Allegheny Campus Boyce Campus North Campus South Campus
808 Ridge Avenue 595 Beatty Road 8701 Perry Highway 1750 Clairton Rd
Pittsburgh, PA 15212 Monroeville, PA 15146 Pittsburgh, PA 15237 West Mifflin, PA 15122
OUR GOAL IS YOUR SUCCESS. Ph: 412.237.4612 Ph: 724.325.6604 Ph: 412.369.3686 Ph: 412.469.6215
Fax: 412.237.2721 Fax: 724.325.6733 Fax: 412.369.3661 Fax: 412.469.6357
The CCAC Supportive Services for Students with Disabilities office provides services to students with diagnosed health
and psychiatric disabilities. To determine eligibility for service, this office requires current and comprehensive
documentation of the disability from the diagnosing physician, psychiatrist, psychologist or other appropriate
professional. All information remains confidential.
Name of Patient ___________________________________________________________________________________
I, _______________________________________ authorize the release of this information dated:__________________
Please provide the following information:
1. Diagnosis, the date of diagnosis and last contact with the student.
2. Describe symptoms meeting the criteria for this diagnosis, level of current functioning and current treatment.
Include the duration and severity of the disorder and expected progression or stability.
3. What functional limitations stem from the disability that may affect the student academically?
4. List current medication(s), dosage, frequency, and anticipated specific impact on the test taker.
5. Recommendations regarding accommodations (i.e., extra time for exams, controlling environment, exam space,
notetakers or other classroom modifications, etc.). Include rationale for these.
For additional comments, please use the back of this page.
Signature:
Date:
Print or type name and title:
License number and area of specialization:
Address:
Phone:
Return this form as soon as possible to the CCAC Supportive Services for Students with Disabilities office at the
individual campus checked below.
Allegheny Campus
Boyce Campus
North Campus
South Campus
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signature
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