PLYM OUTH & QUINCY CA M PUSES
FOCUSED ON TEACHING & LEARNING, ONE STUDENT AT A TIME
Quincy Campus, 1250 Hancock Street, Quincy, MA 023169 Suite 508
Plymouth Campus, 36 Cordage Park, Plymouth MA 02360 Suite 220
DISABILITY SERVICES OFFICE
DISABILITY SERVICE OFFICER: 617- 405-5915 FAX: 617-984-1792
DISABILITY DOCUMENTATION FORM
The licensed clinician or health care provider who is treating this patient
for the diagnosis identified in this document must complete this form.
Student’s Name: ________________________________________________________________
Clinician’s Name: _______________________________________________________________
State Licensure/ Certification #: ___________________________________________________
Area of Specialty: Clinician’s phone#: __________________
The person named on this form is requesting services from the Disability Services Office. The DSO offers services to
students who are considered disabled under the mandates of the Americans with Disabilities Act of 1990 (ADA). Under
the ADA guidelines a person with a disability is one with a physical, mental, emotional or chronic health impairment that
substantially limits one or more major life activity such as caring for oneself, performing manual tasks, walking, seeing,
hearing, speaking, breathing, learning, and working.
I verify that the person named in this document has a substantially limiting disorder that meets the aforementioned ADA
disability criteria: Yes No
If yes, please thoroughly complete this form to document the substantial limitations that are linked to this disorder.
Diagnosis/Description of Psychiatric Disorder or Disability: Please provide full DSM-V code____________________
The extent of the disorder is: Mild Moderate Severe
Initial Date of Diagnosis: Date of last clinical contact:
Expected duration of disorder or disability noted above is:
____Permanent/ Chronic _____Long term: 3-12 months
What is the frequency and duration of symptoms of the student’s condition?
Daily 1/week 1-3/week 1/month 1-3/year Seasonal
None – symptoms under control with medication Other: