Fill - Free fillable Verification Form Psychological Disorder Bucks County Community Colleges (Bucks County Community College) PDF form

Newtown Campus • Student Services Center • Rollins Building • 275 Swamp Road • Newtown • PA • 18940

(215) 968-8182 • (215) 968-8033 fax • accessibility@bucks.edu • http://www.bucks.edu/student/accessibility/

Adapted by permission from The Pennsylvania State University

Verification Form

Psychological Disorder

Bucks County Community College’s Accessibility Office (TAO) has established the Verification Form for Psychological Disorders to

obtain current information from a qualified practitioner (e.g., licensed physician, psychiatrist, clinical psychologist) regarding a

student’s mental health symptoms, related medications, and their impact on the student and his or her need for accommodations.

This Verification Form may supplement information that is provided in other reports, including medical reports or secondary school

documentation. Any documentation, including this Verification Form, must meet Bucks County Community College’s TAO guidelines

for Psychological Disorders. The person completing this form may not be a relative of the student or hold power of attorney over

the student.

A summary of the guideline criteria for documenting Psychological Disorders can be found at the following web site:

http://www.bucks.edu/student/accessibility/student-info/. A summary of the guideline criteria for documenting Psychological

Disorders is as follows:

1. Evidence of current psychological disorder

2. Exclusion of alternative diagnoses

3. Functional limitations affecting an important life skill, including academic functioning

4. History relevant to current psychological disorder

5. Summary and recommendations

Section I: Student Information (Please type information or print legibly)

Student Name:

Last

First

Middle

Student ID:

Date of Birth:

Cell Phone:

Home Phone:

Bucks Email:

Home Email:

Permanent Street

Address:

City:

State:

Zip:

Local Street

Address:

City:

State:

Zip:

Section II: Provider Section (Please type information or print legibly)

A. Contact with the Student:

Date of initial contact with the student:

Date of last contact with the student:

B. Diagnosis Information:

1. Clinical History

Does the student have a clinical history (i.e., prior to age 12) of Psychological Disorder?

Yes

Approximately at what age did the student start to exhibit symptoms?

What date was the student diagnosed with symptoms?

Month

Year

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The Accessibility Office  Bucks County Community College

Psychological Disorder Verification Form

Approximately at what age did the student start to exhibit ADD or AD•HD symptoms?

2. DSM Codes: Please include all pertinent diagnoses or rule-out diagnoses using DSM codes (preferably DSM-5

codes). Please be specific with regard to the diagnosed disorder (i.e., specific anxiety disorder, depressive

disorder, etc.)

Please include all pertinent diagnoses or rule-out diagnoses using DSM codes.

Axis I:

Axis II:

Axis III:

Axis IV:

Axis V (GAF):

3. Current Symptoms

a. Please provide information regarding the student’s current presenting symptoms.

b. Is there clear evidence that the student’s symptoms associated with the psychological disorder are

interfering with or reducing the quality of at least one of the following, including academic functioning?

School (classroom or educational

setting):

Home or work:

With friends or relatives:

In other activities:

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The Accessibility Office  Bucks County Community College

Psychological Disorder Verification Form

4. Student’s History

a. Please include any historical information relevant to the student’s psychological disorder and associated

functioning (e.g., developmental, familial, medical, pharmacological, psychological, psychosocial).

C. Medications:

Is the student currently taking medication(s) for Psychological Disorder symptoms?

Yes

If yes, please provide information below for each medication the student is currently prescribed:

Medication  Dosage  Frequency (e.g., Adderall 5 mg 1 x daily):

Date Prescribed:

Side effects that impact the student’s functioning (e.g., concentration, sleep, thinking, eating, etc.):

Medication  Dosage  Frequency (e.g., Adderall 5 mg 1 x daily):

Date Prescribed:

Side effects that impact the student’s functioning (e.g., concentration, sleep, thinking, eating, etc.):

Medication  Dosage  Frequency (e.g., Adderall 5 mg 1 x daily):

Date Prescribed:

Side effects that impact the student’s functioning (e.g., concentration, sleep, thinking, eating, etc.):

Medication  Dosage  Frequency (e.g., Adderall 5 mg 1 x daily):

Date Prescribed:

Side effects that impact the student’s functioning (e.g., concentration, sleep, thinking, eating, etc.):

Verification Form: Psychological Disorder 4

The Accessibility Office  Bucks County Community College

Psychological Disorder Verification Form

D. Therapies:

Is the student currently participating in psychological therapy (e.g., psychotherapy, group therapy, cognitive-

behavior therapy)? If so, what is the nature of the therapy, how long has the student been in therapy, and how often

does the student participate?

E. Functional Limitations and Recommended Accommodations:

1. Please list the student’s current symptoms associated with the psychological disorder and then indicate what

reasonable academic accommodations would mitigate the symptom listed.

2. Sample: During a bout of depression, a student experiences insomnia and often sleeps during the day causing

class absences.

Symptom: (Example)

Student has been diagnosed with Insomnia.