Q
UINCY
C
OLLEGE
|
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
http://www.quincycollege.edu/departments/disability-services
Created 08/05/13
STUDENT AUTHORIZATION TO RELEASE INFORMATION FORM
To:
Date:
I am requesting services from the Disability Services Office (DSO) at Quincy College. In order to receive
services the DSO requires documentation of my disability. Services at the DSO are solely based on diagnostic
documentation and once this information is in place it will be used to develop a service plan for me.
I hereby authorize you to complete the attached Disability Disclosure Form and release it to the DSO.
I also authorize you to speak with my DSO Specialist in consultation to provide future services. Thank you for
your assistance in this matter.
Sincerely,
__________________________________________ ___________________
Student Signature
Date
____________________________________
Print Name
click to sign
signature
click to edit
Q
UINCY
C
OLLEGE
|
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
http://www.quincycollege.edu/departments/disability-services
Created 08/05/13
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:
Q
UINCY
C
OLLEGE
|
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
http://www.quincycollege.edu/departments/disability-services
Created 08/05/13
DISABILITY DOCUMENTATION FORM PG2
1. Assessment Instruments and Results: (Please describe the procedures used to establish the diagnosis):
2. Medications: Current medications (dosage and side effects):
3. Long term medication plan:
4. Current compliance with medical plan:
5. History of Hospitalization:
6. Does this person create a threat to themselves or others (explain)?
7. Describe the Functional Impact of Symptoms in the Academic Setting:
8. Is this student aware of any realistic limitations regarding how the disorder may impact his/her academic
performance?
Q
UINCY
C
OLLEGE
|
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
http://www.quincycollege.edu/departments/disability-services
Created 08/05/13
DISABILITY DOCUMENTATION FORM PG3
9. Suggested Accommodation:
10. Additional information:
Clinician Signature: ________________________________Date:___________________
Please fax completed document to 617-984-1792.
Submit
click to sign
signature
click to edit
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