Fillable FORM FOR DOCUMENTING PSYCHIATRIC AND LEARNING DISABILITIES: The (California State University, Dominguez Hills)

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FORM FOR DOCUMENTING PSYCHIATRIC AND LEARNING DISABILITIES: The (California State University, Dominguez Hills)

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STUDENT DISABILITY RESOURCE CENTER
James L. Welch Hall (WH) 180
PHONE: (310) 243-3660
EMAIL: dss@csudh.edu
FAX: (310) 928-7267
FORM FOR DOCUMENTING PSYCHIATRIC AND LEARNING DISABILITIES
The outline below was designed to help the student in working with the treating or diagnosing healthcare professional in
obtaining the specific information to evaluate eligibility for academic accommodations.
1) This form is to be filled out by health care professionals qualified to diagnose and recommend accommodations
for students with psychiatric or learning disabilities.
2) All parts of the form must be completed as thoroughly as possible. Inadequate information, incomplete answers
and/or illegible handwriting will delay the eligibility review process by necessitating follow up contact for
clarification.
3) The health care provider should attach any reports which provide additional related information. In addition to
the requested information, please attach any other information you think would be relevant to the student’s
academic adjustment.
Please note that this from does not guarantee accommodations or services. Further assessment and collaboration
between the student and the Student disAbility Resource Center is needed.
AUTHORIZATION FOR RELEASE OF PRIVATE MEDICAL INFORMATION*
TO: ___________________________________________________________________________
(Medical/mental health care professional and/or clinic, medical practice, or hospital)
In accordance with the Health Care information privacy accountability act (HIPAA), and the Federal Education Rights and
Privacy Act (FERPA), I, ____________________________________, authorize and order that the following information
requested on the attached medical release form from California State University Dominguez Hills be completed in total,
by an appropriate licensed professional (as applicable) and returned as soon as possible to the student or to the Student
disAbility Resource Center at California State University Dominguez Hills.
This confidential information will be used to ascertain the educational and functional limitation imposed upon me by my
disability, per the requirements for academic accommodation and services under Title V of the California Educational
Code, Section 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act of 1990. Further, I authorize
and order that the information requested on the attached form from Alliant International University be transmitted in
writing, via United States Mail, facsimile, or electronically, in as expeditions a manner as possible.
This release can be revoked at any time by me with proper notification in writing, and automatically upon my
completion or departure from my studies at California State University Dominguez Hills.
I hereby authorize and order the completion of this order for medical information made b me on this day of -
_________________. I certify that this authorization is made of my own volition, fully in compliance with Federal and
State Laws.
_____________________________________ ______________________________________________
Printed Name of Student Signature of Student
Date Signed: _________________Date of Birth: __________________Student ID#: _________________
*Note: Medical Provider may require additional or alternative release forms.
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signature
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I. Identifying Information: To be filled out by student
Name: _________________________________________________________________
Address: _________________________________________________________________
Date of Birth: _________________________________________________________________
Student ID: _________________________________________________________________
II. Professional Diagnosing Condition/Treatment Information
Professional must be qualified to diagnose a psychiatric disability. If medication is involved, a psychiatrist is preferred.
Today’s Date: _______________
1. Please indicate your profession (circle one):
Psychologist Psychiatrist Medical Doctor Licensed Professional Counselor
Social Worker Marriage Family Therapist Nurse Practitioner: _______________________
(Specialty)
Other: ___________________________________________________________________________
2. How long has this student been under your care? _____________________________________
3. When was the last time you saw this student? ________________________________________
III. Diagnostic Information
1. Date of onset of condition: _______________
2. DSM-5 diagnosis and ICD-10 Code: __________________________________________________
3. Did you make the diagnosis? Yes No
If no, who did? ___________________________________________________________
4. Severity of Condition (circle one):
Mild Moderate Severe
5. Is the condition: Acute or Chronic?
6. Prescribed Medication(s): _________________________________________________________
7. Current treatment: ______________________________________________________________
______________________________________________________________________________
8. Are there any co-existing conditions (physical, mental, cognitive) that should be considered in
the accommodation plan? _________________________________________________________
______________________________________________________________________________
9. What is the prognosis of the condition? ______________________________________________
10. Are there any factors that may exacerbate the condition? _______________________________
IV. Method of Assessment
Method
Indicate which method was utilized
Interview with the student
Interviews with other persons
Behavioral observations
Developmental history
Educational history
Medical history
Rating scales
Neuropsychological testing (please include report
with student’s permission)
Psycho-educational testing (please include report
with student’s permission)
Educational testing (please include report with
student’s permission)
Other:
V. Functional Limitations/Impact on Daily Life Activities
1. What major life activities are affected because of the student’s psychological condition? Indicate the level of
limitation for each.
Area of
Limitation
No
Impact
Moderate
Impact
Don’t
know
Area of
Limitation
No
Impact
Moderate
Impact
Substantial
Impact
Don’t
Know
Learning
Speaking
Memory
Thinking
Concentration
Reading
Writing
Eating
Social
Interaction
Managing
Deadlines
Self-Care
Sleeping
Managing
Internal
Distractions
Managing
Internal
Distractions
Communicating
Test Taking
Stress
Management
Organization
Regular Class
Attendance
Other
(indicate
below):
2. Describe how current symptoms impact the student’s ability to participate in academic or fieldwork
(practicum/internship) experiences.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
VI. Recommended Accommodations
Recommendation for academic and fieldwork (practicum/internship) accommodations: Please include justification for
each accommodation.
Recommended Accommodations
Justification
VII. Certifying Professional (all the following must be filled out completely)
(Please attach your business card)
Print name/Credentials ___________________________________________________________
Signature ___________________________________________________ Date __________________
License number ____________________________________________________________________
Address __________________________________________________________________________
Telephone ________________________________________________________________________
For Office Use
Date Received:
_____/_____/_______
Staff Initials:
2020/01
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FORM FOR DOCUMENTING PSYCHIATRIC AND LEARNING DISABILITIES: The (California State University, Dominguez Hills)

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Completed 28 January 2021

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