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Disability Support Services (Montana State University - Billings)

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Disability Support Services Page 1 of 2 Updated 08/28/2019
Disability Support Services
University Campus
College of Education Rm 135
1500 University Dr.
Billings, MT 59101
(406) 657-2283
FAX (406) 657-1658
City College
Tech. Building, Rm 016A
3803 Central Av.
Billings, MT 59102
(406)247-3029
FAX (406) 247-3014
Video Phone (406) 545-2518
Disability Verification
The student named below has identified you as a licensed professional who is familiar with
him/her. Please assist us in providing appropriate educational services for this student by verifying
his/her diagnosis (diagnoses). In addition, please tell us how the student’s disability may affect
his/her ability to function in an academic environment and any accommodations that you believe
will assist the student in the tasks of learning.
Release of information, to be completed by the student (please print legibly in ink):
Student’s Name: __________________ , ____________________ ________________
Last First Middle Date of Birth
I Authorize the release of information requested below to Disability Support Services at
Montana State University Billings. (Your evaluator may have additional releases for you to sign.)
____________________________________________________ ____________
Student’s Release Signature Date
To be completed by a licensed/certified professional (Please use additional pages as needed)
1. Diagnoses:
3. Level of
Severity:
☐ ☐ ☐ ☐
Mild Moderate Severe Partial
Remission
☐ ☐ ☐ ☐
Mild Moderate Severe Partial
Remission
4. Dates of
Diagnoses:
5. Dates of last
office visits:
Please help Disability Support Services at MSUB and City College to provide the most helpful and effective
educational environment for your client/patient. Take a few moments to consider and answer the following two
questions. We value your knowledge of this student and will seriously consider the information you provide in
developing the individual accommodations that will give this student access to the programs and services of
MSUB and City College.
Disability Support Services Page 2 of 2 Updated 08/28/2019
To be completed by a licensed/certified professional (continued)
Please include a psychological evaluation or psycho-educational evaluation for LD & AD/HD if available. The
report should include the following:
Assessment/evaluation procedures along with scores of all tests administered.
Relevant background information (i.e., history of disability).
I certify that the above referenced client/patient has a “physical or mental impairment that substantially
limits one or more major life activities of such individual” as defined by the Americans with Disabilities
Act.
In addition, I have the necessary professional qualifications to document my client/patient’s disability,
and the information provided on this form is accurate to the best of my knowledge
______________________________________________________________________
Name of professional please print
_______________________________________________ _____________________
Signature of professional Date
Professional Credential _ _____________________________ _____________________
License/Certification #
_________________________________________ _________ ____ ___________
Street Address City State Zip
Please return this form as soon as possible so this student may receive accommodations.
Please include the necessary verifying documents from your files.
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Disability Support Services (Montana State University - Billings)

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Completed 24 August 2020

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