CERTIFICATION OF A LEARNING DISABILITY

The student named below has applied for services from the Disabled Student Services at Lake City Community College. In order to determine eligibility for services, we need documentation of the student's Learning Disability. After completing this form, please mail or FAX it to the Office of Disabled Student Services at the address below. The information you provide will be kept in the student's confidential file at DSS. In addition to the requested information, please attach any additional information: for example, your report and any test results. Thank you for your assistance.

Date: _______________________ Name of Student ___________________________________________

I grant permission for my educational/medical 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 _________________________________________

2. What is your DSM-IV multi-axial diagnosis for this student? Date of Diagnosis _____________________

Axis I:

Clinical Disorders

Axis II:

Personality Disorders, Mental Retardation

Axis III:

General Medical Conditions

Axis IV:

Psychosocial and Environmental Problems

Axis V:

Global Assessment of Functioning

3. 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.

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Structured or unstructured interviews with the person himself or herself.

Interviews with other persons.

Developmental history.

Educational history.

Medical history.

Neuro-psychological testing. Date(s) of testing?

Psycho-educational testing. Date(s) of testing?

Standardized or UN-standardized rating scales.

DSM-III-R diagnostic criteria

DSM-IV diagnostic criteria.

Other (Please specify).

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4. Is this student taking medications(s)? Describe medication(s), date(s) prescribed, effect on academic functioning, and side effects.

5. In your opinion, what functional limitations does this student encounter as a result of his/her Learning Disability? Please provide specific information about limitations when the student is using medication and when the student is not using medication.

6. Is there anything else you would like us to know about this student?

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Signature of Professional

Date

___________________________________________________________

___________________________

Professional's Name (printed) and Title

License No.

 ___________________________________________________________

___________________________________________________________

________________________

Telephone No.

________________________

Address

Fax No.