RANDOLPH-MACON COLLEGE
OFFICE FOR DISABILITY SUPPORT SERVICES

PSYCHOLOGICAL DISABILITY VERIFICATION

STUDENTS - GIVE THIS FORM TO YOUR DIAGNOSTICIAN
*** THIS FORM IS NOT FOR LEARNING DISABILITIES ***

To ensure the provision of reasonable and appropriate services and/or accomodations for students with psychological or attention disorders at Randolph-Macon College, a licensed professional (e.g. psychiatrist, psychologist, physician) must provide current and comprehensive documentation of the student's disability.

Please complete the following form for ______________________________________ who has requested disability-related services and accommodations from the College. (Please print or type).

1.       DSM-IV Diagnosis:

          ______________________________________________________________________________

          ______________________________________________________________________________

2.       Date of Diagnosis:

          ______________________________________________________________________________

3.       Date of your last contact with the student: ______________________________________________

4.       What instruments/procedures were used to diagnose the psychological or attention disorder?

          ______________________________________________________________________________

          ______________________________________________________________________________

5.       Please describe the presenting symptoms of this diagnosis:

          ______________________________________________________________________________

          ______________________________________________________________________________

          ______________________________________________________________________________

          ______________________________________________________________________________

6.       Is this student currently taking medications for this disorder? _____ Yes   _____ No
          If yes, what is the medication?      ____________________________________________________

          ______________________________________________________________________________

 

7.       Please describe the impact of this disorder/disability on the student's academic performance so that
          we can determine the specific accomodations which may be necessary:

          ______________________________________________________________________________

          ______________________________________________________________________________

          ______________________________________________________________________________

          ______________________________________________________________________________

 

Please attach any additional information that you believe to be relevant to the student's disability-
related academic needs.

Signature:     _________________________________________________________________________

Print Name and Title:     ________________________________________________________________

License #:     _________________________________________________________________________

Address:

        Street: __________________________________________________________________

        City: ___________________________________________________________________

        State: ________________________________       Zip: ___________________________

Phone: __________________________________________

Date: ___________________________________________

Return this form by June 1st to:

Randolph-Macon College
Office for Disability Support Services
Higgins Academic Center
P.O. Box 5005
Ashland, VA 23005

Phone: (804) 752-7343
Fax:     (804) 752-3744