Office of Disability Services

Eastern Illinois University

600 Lincoln Avenue

Charleston IL 61920-3099

217-581-6583 (Voice/TTY)

217-581-7208 (Fax)

DOCUMENTATION OF PSYCHOLOGICAL DISORDER

________________________________________ has recently requested accommodations from the Office of Disability Services on the basis of a psychological disability. Your name has been provided as the diagnosing professional, you are requested to complete all sections of this form.

Please return the completed form to the Assistant Director of Disability Services at the above address. Thank you for your prompt reply so we can begin providing services as soon as possible.

Office of Disability Services

Kathy Waggoner, Assistant Director

______________________________________________________________________________

DSM IV

AXIS I: ________ ____________________________________

Code

____________________________________

AXIS II: _________ ____________________________________

Code

____________________________________

AXIS III: _______________________________________________________________

AXIS IV: _______________________________________________________________

AXIS V: _______________________________________________________________

Date of Diagnosis: _______________ Date of Last Visit: ___________________

How often do you regularly meet with the student? _____________________________

II. Does this condition interfere with one of the following major life activities?

ÿ breathing ÿ walking ÿ hearing ÿ seeing ÿ working

ÿ performing manual tasks ÿ learning ÿ caring for self

Please complete the reverse side of this form.

III. Describe the functional limitations and/or behavioral manifestations: (e.g., easily distracted, poor concentration, difficulty focusing for extended period of time, difficulty formulating and executing plan of action, difficulty overcoming unexpected

obstacles, panics in unfamiliar surroundings and situations, etc.) and recommendations you have prescribed:

Behavior Recommendations

__________________ _______________________________________________

IV. List any medication(s) prescribed and side effects being experienced:

_______________________________________________________________________________________________________________________________________________________________________________________________________________

II. Describe information you have concerning this student’s intellectual strengths and weaknesses:

III. The following academic accommodations may or may not be appropriate. Which would you recommend?

ÿ extended time on tests ÿ priority seating ÿ taped class lectures ÿ limited class load ÿ notetakers ÿ priority registration

ÿseparate test administration (distraction free environment)

ÿother. Please specify __________________________________________________

_____________________________________________________________________

CERTIFYING LICENSED PHYSICIAN, PSYCHIATRIST OR CLINICAL PSYCHOLOGIST/LICENSE # ___________________________

________________________________ ______________________________

Physician’s Name Typed or Printed Physician’s Signature

Address______________________________________________________________

Phone__________________________ Date_______________________________