Fillable Psychological And Psychiatric Disorders Documentation Form (Jacksonville University)

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Psychological And Psychiatric Disorders Documentation Form (Jacksonville University)

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JACKSONVILLE UNIVERSITY
Disability Support Services
2800 University Blvd. N.
Jacksonville, FL 32211
Phone: (904) 256-7067 -- Fax: (904) 256-7066
Documentation Guidelines
Welcome to the office of Disability Support Services (DSS) at Jacksonville University (JU). To
be eligible for services at the DSS, a student must satisfy the definition of a disability as
established by the Americans with Disabilities Act of 1973. Section 504 defines a disability
as a condition which substantially limits one or more major life activities such as
learning, walking, seeing, hearing, breathing, caring for oneself, and working. To
be eligible for accommodations, a student must provide appropriate documentation of each
disability that demonstrates an accompanying substantial limitation to one or more major
life activities.
The following guidelines are provided in the interest of assuring that professionals’ statement is
appropriate to document eligibility for support services. The student with a disability must
provide the office of DSS appropriate written documentation from a licensed professional in the
field concerning the specific diagnosis and expected academic limitations.
The documentation must be within the last 3 years. However, the DSS reserves the
right to make modifications to this time frame.
I, __________________, hereby authorize the following information as well as any
other pertinent documentation to be forwarded to the office of Disability Support Services at
Jacksonville University for the purpose of determining my eligibility for academic
accommodations.
Student’s Signature:
Date:
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Documentation Guidelines for Psychological & Psychiatric Disorders
The following information is to be completed by a psychiatrist, psychologist or other
licensed mental health practitioner. After completing this form, please fax or mail it to
the office of Disability Support Services at the address at the end of this document. The
information you provide will not become a part of the student’s educational records but
will be kept in the student’s file at Disability Support Services where it will be kept
confidential. Please contact staff at the office of Disability Support Services if you have
questions or concerns. Thank you for your assistance.
1. Diagnosis:
2. Diagnostic Codes (if applicable):
3. Date of Diagnosis:
4. Most recent GAF score and/or level of severity:
5. Are there any coexisting conditions, including medical disabilities and learning disabilities
that should be considered when providing accommodations (describe if necessary)?
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6. In addition to DSM IV criteria, how did you arrive at your diagnosis? Please check all relevant
items listed below, adding any comments that you think would be helpful to us as we determine
appropriate accommodations and services for this student.
o Interview with the person him/herself
o Interview with other persons
o Behavioral observations
o Developmental history
o Educational history
o Medical history
o Neuro-psychological testing
o Psycho-educational testing
o Educational testing
o Rating scales
o Other (please specify) ______________________________
Comments:
Please attach copies of testing reports if available.
7. Relevant test results or clinical observations used to determine diagnosis:
8. Describe symptoms which meet the criteria for diagnosis, and how these symptoms impact the
individual’s ability to perform in a college setting:
9. What is the student’s prognosis? How long do you anticipate the student’s performance in a
college setting will be impacted by the disability?
10. Is the diagnosis permanent or temporary?
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11. Please check below the major college life activities that are affected to a substantial degree
because of the disability:
Eating
Writing
Sleeping
Test-Taking
Learning
Regular class attendance
Organization
Managing deadlines
Focusing or concentrating
Stress management
Memory
Classroom group functioning
Reading
Memory
Classroom group functioning
Social interactions
Other (please specify):
12. Date of first visit:
Date of last visit:
Frequency of visits:
13. What medications is the student currently taking? Do limitations persist, even with
medication? How might side effects, if any, affect the student’s academic performance?
14. What procedures or tests were used to determine functional limitations?
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15. What are the student’s functional limitations in an academic setting?
16. Please attach any additional documentation and/or testing results which may help us determine
the most appropriate assistance for this student.
17. Please indicate below your recommendations regarding academic accommodations and
accompanying justifications for the student (e.g., note-takers, extended time for tests, etc.).
Accommodation
Justification
1.
1.
2.
2.
3.
3.
4.
4.
5.
5.
6.
6.
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Student Name:
Professional Signature:
Date:
Print Name, Title, Degree:
Professional License Number:
Contact Information:
Thank you for your prompt response to this request. Please return this information to:
Olga L. Florez, M.Ed., M.P.A
Director, Disability Support Services
Davis Student Commons, 3
rd
floor
Division of Student Affairs
2800 University Blvd. N.
Jacksonville, FL 32211
Email: oflorez@ju.edu
Phone: (904) 256-7067 -- Fax: (904) 256-7066
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Psychological And Psychiatric Disorders Documentation Form (Jacksonville University)

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Completed 24 July 2020

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