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?
are the functional limitations or symptoms (due to disability or medication side effects)?
accommodations are appropriate to compensate for the limiting functions mentioned above?
s 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
click to sign
click to edit