Queen’sStudentAccessibilityServices
Queen’sUniversity
CôtéSharpWellnessCentre,MitchellHall
69UnionStreet|Kingston,ON|K7L3N6
613‐533‐2506
https://www.queensu.ca/studentwellness/accessibility‐services/
DisabilityVerification
DisabilityCategory:DEVELOPMENTALDISORDER
Thisformshouldbecompletedbyoneofthefollowingappropriatelylicensedandtrainedprofessionals:
Psychologist,Psychiatrist,DevelopmentalPediatrician,FamilyPhysician
Pleaseprintclearlyinblackink
STUDENTINFORMATION:
LastName:_________________________ Preferred/GivenName:__________________________
DateofBirth:________________________ StudentNumber:______________________________
Queen’sNetID:___________________________ Phone:_______________________________________
FIELDWORK/PLACEMENTS:
Willyouberequiredtocompletefieldwork(placements/practicums/co‐op)?
YES NO
TypeofFieldwork:__________________________________________________________________________
DateFieldworkBegins:
DISCLOSUREOFDIAGNOSIS:
Note:YouareNOTrequiredtodiscloseyourmedicaldiagnosisinordertoreceiveaccommodationsandsupports.
However,QSASdoesrequireverificationofthenatureofyourdisabilityand,moreimportantly,informationabouthow
itimpactsyouatuniversity.QSASwillusethisinformationtorecommendappropriateaccommodationsandsupports
foryouatQueen’s.
CONFIDENTIALITY:
InformationprovidedtoQSASinthisform,includinganymedicaldiagnosis(es),iskeptstrictlyconfidential.Itisnot
sharedwithanyoneoutsideofQSAS,includingwithotheruniversitydepartments,withouttheexpressedandwritten
consentand/ordirectionofthestudent.
Doyouconsenttoyourmedicaldiagnosisbeingidentifiedonthisformand
communicatedtoQueen’sStudentAccessibilityServices?
YES
NO
RELEASEOFINFORMATION:
IherebyauthorizemyHealthCareProfessional(HCP),whoiscompletingandsigningthisform,toshareinformation
withQueen’sStudentAccessibilityServicesaboutmydisabilityanditsfunctionalimpacts.
StudentSignature: Date:

PersonalinformationiscollectedundertheauthorityoftheQueen’sUniversityRoyalCharter,1841(asamended)andwillbeusedtoprovidedisability‐
relatedservicesandaccommodationsforstudiesatuniversity.
Student’sInformedReleaseisdoneinaccordancewiththefollowingsectionsoftheFreedomofInformationandProtectionofPrivacyAct:41.(1)(a),
41.(1)(b),and41.(1)(c)allowingfortheuseofpersonalinformationandsections42.(1)(b),42(1)(c),and42(1)(d)allowingforthedisclosureofpersonal
information.
click to sign
signature
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HEALTHCAREPROFESSIONAL:
Queen’sUniversityisrelyingon,andappreciates,yourdetailedknowledgeofthisstudent’sdisability,especiallyhowits
limitationsorrestrictionsmayimpactontheirlearningatuniversity.Carefulconsiderationshouldbegiventothe
verificationofdisabilityanddegreeoffunctionallimitationinthesectionsbelow.
VERIFICATIONOFDISABILITY:
Ifthestudentconsentedabovetodisclosetheirmedicaldiagnosis,pleaseprovideacleardiagnostic
statement.IncludeDSM‐5Codediagnosisandlevelofseverity.Note:Indicateanyco‐existingdiagnosesor
concurrentconditions,includingDSM‐5codewhereapplicable.
DURATION:
PERMANENT:Ongoing,willimpactthestudentoverthecourseoftheiracademiccareer,andis
expectedtoremainfortheirnaturallife
PERMANENT,EPISODIC:Periodsofgoodhealthinterruptedbyperiodsofillnessordisability,andis
expectedtoremainfortheirnaturallife
TEMPORARY: AnticipatedDuration ______/______(MM,YR)to ______/______(MM,YR)
PROVISIONAL:
Iamstillmonitoring/assessingthestudent.
Assessmentlikelytobecompletedby:______/______/______(DD,MM,YR)
NextClinicalAssessmentDate(ifapplicable):______/______/______(DD,MM,YR)
Ifdurationisunknown,pleaseindicateareasonabledurationforwhichthestudentshouldbe
accommodated:_____________________(numberofmonths)orwhichTERM(S):
FALL WINTER SPRING/SUMMER
PleaseNote:InterimAcademicAccommodationsmaybeprovidedduringtheassessmentperiod.Toextend
theseaccommodations,updateddocumentationmayberequiredforconditionsstillbeingassessed.
ASSESSMENTINFORMATION:
Howlonghasthestudentbeenyourpatient?
Seenforfirsttimetoday 1weekorless 6monthsorless
1yearorless Morethan1year
Willyoubemonitoring/treatingthisstudentwhiletheyareatQueen’s?
YES NO
CLINICALASSESSMENTMETHODSUSED.CHECKALLTHATAPPLY:
ClinicalAssessment Date(s):_____________________________________________________
GlobalAssessmentofFunctioning(GAF)orWHO‐DAS
Score: _________________________
PsychiatricEvaluation Date(s):_____________________________________________________
Neuropsychologicalorpsycho‐educationalassessment Date:__________________________
Pleaseprovideacopy,includingalistoftestscompletedandscores.
BehavioralObservations
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HCPInitial
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DISABILITYINFORMATION:
Pleaseindicatelevelofseverity: Mild
Moderate Severe
DateofOnset:______/______/______(DD,MM,YR)
Dateofmostrecentassessment:______/______/______ NextAssessment:______/______/______
Hasthestudentbeenhospitalizedfortreatmentofthisdiagnosis? YES
NO
Ifyes,pleaseindicatedateofmostrecenthospitalization:______/______/______
Doesthestudenthaveahistoryofself‐injuryorinjurytoothers?
YES
NO
Doesthestudenthaveahistoryofseizures?
YES
NO
Ifyes,hasasafetyplanbeenestablished?
YES
NO
CURRENTTREATMENT‐Optional:(CheckallthatApply)
Psychotherapy BehavioralTherapy
Grouptherapy OccupationalTherapy
Complementarytherapies(e.g.,yoga,meditation) Physiotherapy
SkillsTraining(e.g.,Social,Self‐Regulation,etc.) Other:
Isthestudentcurrentlytakingmedicationfortheirsymptoms?
YES
NO
Ifyes,pleasespecifyanysideeffectsthatimpactonthestudent’sfunctioning?
v
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RESTRICTIONSANDLIMITATIONS:
Inthefollowingsection,pleaseindicateseverityofdisabilitybasedonthenumberandseverityof
symptoms/restrictions,andtheirimpactonthestudent’sfunctioninginauniversityacademicenvironment.
Pleaseusethefollowingscale:
Note:TheHealthCareProvidermustcompletethissectioninconsultationwiththestudent.Students
shouldnocompletethissectionindependentlywithoutinputfromtheirHealthCareProvider.
Mild:
Noimpact,ormildimpact.Thestudentdoesnotrequireacademicaccommodation.
Moderate: Symptomsareprominent.Thestudentwillrequiresomeacademicaccommodation.
Serious:
Thestudenthasahighdegreeofimpairment.Symptoms/restrictionsmarkedlyinterfereswithacademic
functioning.Studentwillrequiresignificantacademicaccommodation.
Severe:
Symptoms/restrictionssoseverethatstudentisunabletofunctionatanylevelinauniversityacademic
environment,evenwithsignificantacademicaccommodation.
Symptoms/Restrictions Mild Moderate Serious Severe Comment
PHYSICAL:
Repetitiveand
StereotypicalBehavior

PoorCoordination/
ClumsyMovements

Headache

SensitivitytoTactileor
OlfactoryStimuli

SensitivitytoVisual
Stimuli

SensitivitytoAuditory
Stimuli

SLEEP:
Insomnia

PoorSleepHygiene

TroubleFallingAsleep

SleepApnea

THINKING:
DifficultyProcessing
AuditoryInformation

DifficultyProcessing
VisualInformation



Queen’sStudentAccessibilityServices
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HCPInitial
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
Symptoms/Restrictions
Mild Moderate Serious Severe Comment
DifficultyProcessing
InformationQuickly

DifficultyConcentrating

DifficultyRemembering

Difficulty
Organizing/Planning

DifficultyReasoning&
ThinkingRationally

DifficultyManagingTime
(incl.freetime)

S
OCIO‐EMOTIONAL:
DifficultyRespondingto
Non‐VerbalSocialCues

DifficultyRespondingto
CommonSocialCues

DifficultyUnderstanding
PersonalSpace

DifficultySelf‐Regulating
inDailyActivities

DifficultyInteractingwith
Others

DifficultyExpressing
Empathy

Irritability

Nervousness

LowMotivation

DifficultyMaking
Decisions

DifficultyManaging
RegularStress

DifficultyManaging
InternalDistractions

DifficultyManaging
ExternalDistractions



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HCPInitial
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COMMUNICATION:
Symptoms/Restrictions
Moderate Serious Severe Comment
DifficultyUnderstanding
Language& Emphasis
ToneVariation
DifficultyUnderstanding
Humor,Metaphors,
Sarcasm
RepetitiveQuestionsor
Comments
SpeechMonotonous,
Rigid,orUnusuallyFast
ACTIVITIES‐Optional:(CheckallthatApply)
Usingthesamescaleabove,pleaseindicatethelevelofimpactofthestudent’sdisabilityandtheirassociated
symptoms/restrictionsonthefollowingactivitiesexpectedoftheminauniversityenvironment:
Activity
Mil
d
Moderate
S
erious
S
evere Comment
AttendingClass
TakingNotes
Reading
Writing
CompletingExams
DeliveringPresentations
MeetingAssignmentDeadlines
ParticipatinginGroupActivities
AdaptingtoScheduleChanges
ParticipatinginLabActivities
AppropriateClassroom
ParticipationandBehavior
Other
Other
Mild
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COURSELOAD:
Isthestudent’sconditionsufficientlystableatthistimetosustainparticipationin
regularuniversityacademicactivities?
YES NO
Inyouropinion,isthisstudentabletomeetthedemandsofafullcourseload(15‐
20hoursofclass,lab,ortutorialmeetingsperweek,plus25‐30hoursofstudytime
perweek?
YES NO
Ifno,pleaseestimatethemaximumamountoftimeinhoursperweekthatthestudentshouldbeableto
spendintheseactivities:_____________________________
AdditionalInformation(Pleaseusethisspacetoprovideanyotherinformationaboutthestudent’sdisabilityandtheir
functionallimitationsthatQueen’sshouldconsiderinsupportingthestudent)
HEALTHCAREPROFESSIONALINFORMATION:
Name:
(PleasePRINT)
FacilityNameandAddress(PleaseuseOfficialStamp)
(Note:Ifyoudonothaveanofficestamp,pleasesign,date,andattachapageofyourOfficeLetterhead)
Specialty:
PsychiatristNeuropsychologist
FamilyPhysician Psychologist
DevelopmentalPediatrician
Other
HealthCareProfessionalSignature: Registration/LicenseNo.:
Date: Phone:
Fax:
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signature
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