Fillable Psychological Disability Documentation Form (Raritan Valley Community College)

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Psychological Disability Documentation Form (Raritan Valley Community College)

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DisabilityServices
P.O.Box3300*Somerville,NJ08876
Phone:(908)526‐1200ext.8534
Fax(908)526‐3494
disabilityservices2@raritanval.edu
Psychological Disability Documentation Form
Please complete this form with as much detail as possible, as a partially completed form or limited responses
may hinder the eligibility process. It is most important that you thoroughly explain any psychological
symptoms and indicate their impact on functioning. If you wish to provide additional information, please attach
it to this form.
Thank you for your assistance.
To be completed by the treating, licensed healthcare professional only
Student’s name: ___________________________________________________________________________
Today's date: ________________________
Date of diagnosis: ____________________________________
Date student was last seen: ________________________________
DSM Diagnoses
Axis/Category I: _________________________________________
Axis/Category II: ________________________________________
Axis/Category III: ________________________________________
Axis IV (if needed): ______________________________________
Axis V (if needed) (GAF Score): Present time: ______________ Over last year: _____________________
In addition to DSM criteria, how did you arrive at your diagnosis? Please check all items that apply below:
Structured or unstructured interviews with patient.
Interviews with other persons: ______________________________
Behavioral observations
Developmental History
Educational History
Medical History
Neuropsychological testing. Dates/Instruments: _____________________________
Psycho-educational testing: Dates/lnstruments: _______________________________
Standardized rating scales: __________________________________
Other: ___________________________________
What is the severity of the condition? Mild Moderate Severe
DisabilityServices
P.O.Box3300*Somerville,NJ08876
Phone:(908)526‐1200ext.8534
Fax(908)526‐3494
disabilityservices2@raritanval.edu
What is the expected duration? Chronic (more than a year) Episodic Short-term (six months - one year)
Please explain severity and duration: ___________________________________________________________
Provide information regarding the impact, if any, of the condition on a specific major life activity (e.g.,
learning, eating, walking, interacting with others, etc.):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
State the student’s functional limitations from the disorder specifically in a classroom or educational setting:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
List the student’s current medication(s), including dosage, frequency, and adverse side effects (if applicable):
__________________________________________________________________________________________
__________________________________________________________________________________________
Are there significant limitations to the student’s functioning directly related to the prescribed medications?
___ Yes ____ No If yes, explain: ____________________________________________________________
Please provide your specific recommendations (based upon your assessment, the student’s clinical and
academic history, and diagnosis) for reasonable accommodations that you believe will help equalize the
student’s ability to access the RVCC’s educational program along with rationale for each):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
DisabilityServices
P.O.Box3300*Somerville,NJ08876
Phone:(908)526‐1200ext.8534
Fax(908)526‐3494
disabilityservices2@raritanval.edu
Additional information you believe would be helpful in determining the nature and severity of this student’s
disability, and any additional recommendations that may assist DS in determining appropriate accommodations:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Certifying Professional
____________________________________ ______________________________
Name and Title Area of Specialty
____________________________________ ______________________________
License Number State of Licensure
____________________________________ ______________________________
Address Phone Number
____________________________________ ______________________________
City, State, Zip Fax Number
____________________________________ ______________________________
Signature of Certifying Professional Date
Please return to:
Office of Disability Services
Raritan Valley Community College
118 Lamington Road
College Center, C-124
Branchburg, NJ 08876
Fax: (908) 526-3494
Email: disabilityservices2@raritanval.edu
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Psychological Disability Documentation Form (Raritan Valley Community College)

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Completed 26 July 2020

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