Office of Student Accessibility 24255 Pacific Coast Highway T: 310-506-6500 F: 310-506-6776
Malibu, CA 90263-6500
Physician/provider name (print): Title:
Phone: Fax:
Organization & address:
This form must be completed by the Medical/ Mental Health Professional listed above.
Diagnosis(es)/DSM Codes: Diagnosis date:
Level of Severity: Mild Moderate Severe
Duration: Permanent Chronic/recurring (Likely to last the duration of college attendance)
Temporary Date disability will end: (Accommodations not necessary after this date)
What assessments/instruments were used to determine diagnosis?
What treatment and/or medications are currently being used?
What are the functional limitations or symptoms (due to disability or medication side effects)?
What accommodations are appropriate to compensate for the limiting functions mentioned above?
This information is current and accurate to the best of my knowledge based on my recent evaluation
of this patient and/or my review of records.
Physician/Therapist Signature License # Date
Student name: Birthdate:
I am requesting academic support services through the Office of Student Accessibility at Pepperdine
University. Pepperdine requires current and comprehensive documentation of my disability/medical
condition. Please respond to the following questions as soon as possible and forward by mail or fax
listed. Students: You may submit this form through secure email at attachments.pepperdine.edu.
click to sign
signature
click to edit
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