Fillable Form 37: Verification of Disability Form for Mental (Columbia University)

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Form 37: Verification of Disability Form for Mental (Columbia University)

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______________________________________________________________________________________________
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Student Name: UNI: _______________________
Date student was last seen: _______________________________________________________________________
Dates of treatment with current provider/facility: _____________________________________________________
Current Principal DSM-V Diagnosis with numerical code including specifier and subtype, if applicable:
Date of Diagnosis:
Additional Diagnosis(es) in the order of focus of attention and treatment :
Associated Medical Condition(s), if applicable:
Date of Diagnosis:
Date of Diagnosis:
Date of Diagnosis:
Date of Diagnosis:
Current Status of each of the above condition(s) (e.g. Active, Progressing, Controlled, In Remission):
1
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This document contains both information and form fields. To read information, use the Down Arrow from a form field.
Wien Hall, Suite 108A
4
11
W.
11
6th S
tr
ee
t,
Ma
il
Co
de
37
14
N
ew
York, NY 10027
Phone
(21
2)
854-2388
(Vo
i
ce
/
TTY
)
Fax
(
212
)
854-3448
disability@
co
l
umbia.edu
www.
hea
lth.co l
umb
ia.e
du
/
ods
Verification of Disability Form for Mental Health Treatment Providers
Purpose: The student named below has indicated that s/he has a disability and will require reasonable
accommodations to participate in a program or activity at Columbia University. The information you provide will be
one of the criteria used to evaluate the student’s eligibility for the requested accommodations or services. Please
take the time to complete this form in its entirety. All information provided will be kept confidential in accordance
with the Family Educational Rights and Privacy Act (FERPA).
In addition to DSM-V criteria, how did you arrive at your diagnosis?
Please check all that apply.
Clinical
interviews
with
student
Review of
medical
records
Interviews
with
other
persons
Review of educational
records
Behavioral observations Neuropsychological testing (include dates):
Standardized rating scale/assessment (please specify):
Other (please specify):
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Be as specific and detailed as possible to what exacerbates the student’s condition(s) and any relevant
psychosocial and contextual factors:
1. Student’s treatment history:
2. Current treatment plan and expected duration of treatment (psychotherapy, medication, etc.):
Please describe the way(s) that the student’s condition presents for the student and/or how the student is
individually impacted:
2
In your current clinical assessment, please indicate the degree of the student’s functional limitations on most
days, keeping in mind the positive and negative effects of any treatment modalities and/or their personal
circumstances:
Mild Moderate Substantial Severe
Please provide details regarding the following:
Please provide the following information regarding any medications related to the condition(s) that the student is
currently prescribed:
Medication Dosage Frequency Positive Effects Adverse effects
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1) Time management and organization: ____________________________________________________________
2) Executive Functioning/ planning:________________________________________________________________
3) Self-care or social interactions: _________________________________________________________________
4) Sleeping: ___________________________________________________________________________________
5) Cognitive processes such as concentration, memory, rapidity of information processing, fatigability: ________
6) Ability to attend or participate in class: __________________________________________________________
7) Learning: ___________________________________________________________________________________
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What are the student’s current functional limitations with respect to the following areas? Please list below:
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8) O
ther: ______________________________________________________________________________________ -
Recommended accommodation: __________________________________________________________________
Rationale: _____________________________________________________________________________________
Recommended accommodation: __________________________________________________________________
Rationale: _____________________________________________________________________________________
Recommended accommodation: __________________________________________________________________
Rationale: _____________________________________________________________________________________
Anticipated duration of need for accommodation: ___________________________________________________
Other pertinent information that would be helpful when determining accommodations for student:
4
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Ple
ase provide specific recommendations regarding academic accommodations for this student, and a rationale
as to why these accommodations/services are warranted, based upon the student's functional limitations (e.g. if
a note taker is suggested, state the reasons for this request related to the student's symptoms).
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5
Name & Credentials of Treatment Provider: ________________________________________________________
License #: _____________________________________________ State: _________________________________
Address: ______________________________________________________________________________________
Telephone: ____________________________________________________________________________________
Signature: ___________________________________________ Date: ___________________________________
Please check the following that apply:
I am the primary person involved in the student’s treatment
I am a part of the student’s treatment team
The student is my former patient, who is currently under the care of another provider
I was the original person who diagnosed this student as having a disability
I hereby certify that the above information is true and correct and that the information provided is objective
medical/ psychological information relative to this student’s application for disability accommodations.
I am not related to the student by blood or marriage
Revised February 2015
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Form 37: Verification of Disability Form for Mental (Columbia University)

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Completed 22 February 2022

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