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Psychological-Docum-1-03 - Psychological-Docum-1-03

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Wichita State University, Wichita, Kansas 67260-0132 Voice/TDD (316) 978-3309 Fax (316) 978-3114
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WICHITA STATE UNIVERSITY
Office of Disability Services
Documentation of Psychological Disabilities
(To be completed by a qualified professional.)
Date:
Student Name: _____________________________________________________________
Home Address: _____________________________________________________________
City_____________
State_________
Zip Code____________
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Telephone: (________)_____________________
Student signature to release requested information:
______________________________________
The above student has requested that you complete the following information to verify their disability.
To ensure the provision of reasonable and appropriate services for students with psychological
disabilities, students needing such services are required to provide current and comprehensive
documentation of their disability. We ask that you complete the following sections or provide a written
report that addresses all the areas listed below. Any information you can provide that offers
recommendations for necessary and appropriate auxiliary aids or service, academic adjustment, or other
accommodation is appreciated.
Date of Diagnosis ____________________
Diagnosis (DSM criteria) ______________________________________________
Process used to determine diagnosis.
Diagnostic Interview Summary
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Wichita State University, Wichita, Kansas 67260-0132 Voice/TDD (316) 978-3309 Fax (316) 978-3114
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Level of Severity (circle one)
Mild
Moderate
Severe
Measures used to assess the following if applicable.
Aptitude
Achievement
Information Processing
Social – Emotional
Provide a summary of the student’s educational, medical, a nd family history that may
relate to psychological disability.
QUALIFIED PROFESSIONAL’S SIGNATURE _____________________________
PRINTED NAME AND TITLE ________________________________________
ADDRESS: __________________________________________________________
DAYTIME TELEPHONE: (____)__________________
Return this form to
Wichita State University
Director, Disability Services
1845 Fairmount
Wichita, KS 67260-0132
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Psychological-Docum-1-03 - Psychological-Docum-1-03

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Completed 11 March 2020

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