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CERTIFICATION OF EMOTIONAL/MENTAL DISABILITY
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The student named below has applied for services from the Disabled Student Services (DSS) at Lake City Community College. In order to determine eligibility and to provide services under the Americans with Disabilities Act (ADA) of 1990 and Section 504 of the Rehabilitation Act of 1973, we require documentation which indicates that a specific disability exists and that the identified disability substantially limits one or more major life activities. The documentation must also support the requested accommodations and academic adjustments.
After completing this form, please mail or FAX it to us at the address at the end of the form. The information you provide will be kept in the student's file at DSS, where it will be held strictly confidential. In addition to the information you provide on the form, attach any other information you think would be helpful to the student's academic adjustment. Please contact us if you have questions or concerns. Thank you for your assistance.
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Date: ____________________ Name of Student _________________
I grant permission for my medical/mental health provider to release (copies of) information regarding my disability, the diagnosis, treatment and accommodation recommendations to the Office of Disabled Student Services at Lake City Community College.
Signature ________________________________________________
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Date of Diagnosis (below):__________________
Student was last seen __________________
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| DSM-IV diagnosis:
Axis I: ______________________________________________________
Axis II: _____________________________________________________
Axis III: _____________________________________________________
Axis IV: _____________________________________________________
Axis V (GAF score): ___________________________________________________________
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| 1. In addition to DSM-IV criteria, how did you arrive at your diagnosis? Please check all relevant items below, adding brief notes that you think might be helpful to us as we determine which accommodations and services are appropriate for the student.
Top of Form
Structured or unstructured interviews with the person himself or herself.
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Interviews with other persons.
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Behavioral observations.
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Developmental history.
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Educational history.
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Medical history.
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Neuro-psychological testing. Date(s) of testing?
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Psycho-educational testing. Date(s) of testing?
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Standardized or un-standardized rating scales.
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Other (Please specify).
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Top of Form
2. Please check which of the major life activities listed below are affected because of the psychological diagnosis. Please indicate the level of limitation.
Life Activity
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No Impact |
Moderate Impact |
Substantial Impact |
Don't Know
Concentrating
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Memory
Sleeping
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Eating
Social Interactions
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Self-care
Managing internal distractions
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Managing external distractions
Timely submission of assignments
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Attending class regularly and on time
Making and keeping appointments
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Stress management
Organization
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Bottom of Form
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| 3. What other specific symptoms manifesting themselves at this time might affect the student's academic performance?
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| 4. What medications is the student currently taking? How effective is the medication? How might side-effects, if any, affect the student's academic performance?
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| 5. What is the student's prognosis? How long do you anticipate that the student's academic achievement will be impacted by his/her disability?
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6 Months |
1 Year |
More
than 1 year
Check one:
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| 6. Is there anything else you think we should know about the student's psychological disability?
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| CERTIFYING PROFESSIONAL*
Printed Name: _______________________Signature: _______________
License Number: ____________________ Phone: ______________
Fax: ___________
Address: ___________________________________________________________
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