Psychological Documentation Form
STUDENT NAME: _________________________ STUDENT PHONE: ____________________
STUDENT EMAIL(S):______________________________________________________________________________
STUDENT MAILING ADDRESS: _____________________________________________________________________
STUDENT: Please have this form completed by a qualified professional and return it to the Disability and Learning
Resource Center (address on following page).
To ensure the provision of reasonable and appropriate services for students with psychological disabilities at The
School of the Art Institute of Chicago, a licensed clinician (e.g. physician, psychologist, psychiatrist) must provide
current and comprehensive documentation of the differential diagnosis of the student’s disability. The current ADA
views a disability as a physical or mental impairment that substantially limits one or more major life activities, such as:
manual tasks, walking, seeing, hearing, speaking, breathing, learning, thinking, concentrating, or working.
Please complete the following form for ________________________________ who has requested disability-related
services and accommodations from our office. (Please print clearly or type.)
1. DSM-IV Diagnosis and comorbid conditions, if any: _________________________________________
2. Date of Diagnosis: ____________________________________________________________________
3. Date of your last contact with the student: ________________________________________________
4. What instruments/procedures were used to diagnose the psychological disorder?
5. Please describe the current symptoms of this disorder.
6. What is the expected duration, stability, and/or progression of this disorder?
7. Please briefly describe the current treatment, including medications including any possible side effects of the
Revised 06/13
8. Please describe the current functional impact of this disorder/disability on the student’s daily activities and academic
performance so that we can determine the specific accommodations which may be necessary.
9. If the student is requesting accommodations in a residence hall, please discuss the limitations to a major life function
and suggested means of accommodating this limitation.
10. What accommodations (e.g. testing modifications, adjusted course load, wheelchair accessible room, etc.) would you
suggest to enhance this student’s chance for success?
Signature: ____________________________________________ Date: _________________________
Name: _______________________________________________________________________________
Title: ________________________________________________________________________________
License #: ____________________________________________________________________________
Address: _____________________________________________________________________________
Phone: ____________________________________________
Please return this form to:
Attn: Valerie St. Germain
Disability and Learning Resource Center
The School of the Art Institute of Chicago
116 S. Michigan Avenue 13
Chicago, IL 60603
(312) 499-4278 Office
(312) 499-4290 (fax)
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