MED
FOLSOM LAKE COLLEGE/EL DORADO CENTER
DSP&S DISABILITY VERIFICATION
Disabled Student Programs & Services
DATE:________________
Name: __________________________________________ Medical Record#:____________________ D.O.B:____________
Address: ____________________________________________________________ SS/ID#: _____________________________
Phone #:________________________________
In order to receive disability-related services at Folsom Lake College/EDC a verification of disability must be provided. I request that
the professional designated below complete this form.
Name of Licensed or Certified Professional:______________________________________________________
Address:____________________________________________________________________________________
Please provide the following information in full in order to help determine reasonable educational accommodations to support
this student:
1. Diagnosis: __________________________________________________________________________________________
2. DSM IV Code and Severity (if applicable) __________________________________________________________________
3. Please describe how this condition substantially limits major life activities:_________________________________________
________________________________________________________________________________________________
4. Condition is: Stable Prone to exacerbation
5. Duration of Disability: Permanent/Chronic
Temporary (date of re-evaluation or estimated duration of disability __________________
Educational, medical, and/or psychological documentation should be attached and returned to:
College—Attn: Disabled Student Programs & Services, Folsom Lake College, 100 Clarksville Road, Folsom, CA 95630
Student—See Address Above
MEDICAL VERIFICATION FOR:
THIS SECTION MUST BE COMPLETED BY THE LICENSED OR CERTIFIED PROFESSIONAL
I understand that the information provided by the verifying professional will become part of the student record, and may be
released to the student upon their written request.
Verifying Professional Signature:________________________________________ Date: __________________________
If the abov
e information is completed by someone other than the professional who made the diagnosis, please provide the name and address of
the person who made the diagnosis :__________________________________________________________________________________________
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