Disability Support Services

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 1^st 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

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 ***

RANDOLPH-MACON COLLEGE
OFFICE FOR DISABILITY SUPPORT SERVICES

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