Fillable PSYCHOLOGICAL DISABILITY DOCUMENTATION REQUEST FORM (SOWELA Technical Community College)

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PSYCHOLOGICAL DISABILITY DOCUMENTATION REQUEST FORM (SOWELA Technical Community College)

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Disability Services
PSYCHOLOGICAL DISABILITY DOCUMENTATION
REQUEST FORM
****This form must contain ALL of the REQUESTED INFORMATION and be TYPED or
PRINTED in order to apply for accommodations through Disability Services.****
Student’s Name: ________________________________________________________________
Date of Birth: __________________________________________________________________
Address: ______________________________________________________________________
Phone Number: _________________________________________________________________
B#:___________________________________________________________________________
This student is requesting an auxiliary aid or service, academic adjustment, and/or other accommodations from
Disability Services. In order to consider this request, as well as to ensure the provision of reasonable and
appropriate auxiliary aids and services, College Policy requires that a Qualified Professional provide current and
comprehensive documentation. A qualified professional is a licensed mental health professional who is not a family
member of the student. IN ORDER TO BE CONSIDERED CURRENT, THE QUALIFIED PROFESSIONAL’S
STATEMENT MUST BE WITHIN 6 MONTHS PRIOR TO THE DATE OF THE MOST RECENT REQUEST
FROM DISABILITY SERVICES.
The documentation provided must include information that indicates a diagnosis of a psychological disability (must
make a DSM-IV TR diagnosis), describes the functional limitations in an educational setting, indicates the severity
and longevity of the psychological disability for the purpose of determining academic adjustment(s) or other
accommodation(s), and lists current medication and any current side-effects which may impact academic
performance.
To facilitate the gathering of such critical information, please respond to the following and return to SOWELA,
Disability Services.
1. Diagnosis: ________________________________________________________________________________
2. Date of Diagnosis: __________________________________________________________________________
3. Date of Last Contact with Student: _____________________________________________________________
4. Provide a summary of the student’s educational, medical, and family history that relates to the psychological
disability (difficulties must be related to the diagnosed disability and are not the result of other conditions,
cultural differences, or insufficient instruction):
5/2012 1
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5. Describe the student’s functional limitations in an educational setting:
6. List current medication along with any current side effects that may impact academic performance:
7. Please indicate the RECOMMENDATIONS you have regarding necessary and appropriate auxiliary aids or
services, academic adjustments, or other accommodations to equalize the student’s educational opportunities at
SOWELA as justified based of the functional limitations indicated above.
Please check all that apply: ___ extended time (1.5x) ___ distraction-reduced environment
___ class notes ___ consideration for absences ___ no scantron
___ reader ___ scribe
___ other ________________________________________________________________________________
Qualified Professional’s Signature: _______________________________________________________
Printed Name & Title:__________________________________________________________________
Daytime Telephone Number: ____________________________________________________________
Address: ____________________________________________________________________________
Date: _______________________________________________________________________________
NOTE: Our policy regarding documentation prohibits the dissemination of documentation to you or anyone
requesting it once it is received. Therefore, once this form is submitted, we will be unable to disseminate copies to
anyone.
SOWELA Technical Community College does not discriminate on the basis of race, color, national origin, gender,
disability, or age in its programs and activities. The following person has been designated to handle inquiries
regarding non-discrimination policies: Compliance Officer, 3820 Sen J Bennett Johnston Ave, Lake Charles, LA
70615, ph: 337-421-6565 or 800-256-0483, Email complianceofficer@sowela.edu
Disability Services
5/2012
SOWELA Technical Community College
3820 Sen. J. Bennett Johnston Ave.
Lake Charles, LA 70615-6829
Phone: (337) 421-6969
Fax: (337) 491-2054
2
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Completed 17 September 2020

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