Verification Form: Diagnosed Psychological Conditions

NOTE: This form is to be filled out, in its entirety, by a MENTAL HEALTH PROFESSIONAL WHO IS CURRENTLY TREATING THE STUDENT. This professional must be unrelated to the student, and any information provided by a family member will be considered supplemental. Forms with insufficient detail will prompt a request for more information. PLEASE TYPE AND SUBMIT THIS FORM ELECTRONICALLY, rather than hand-writing or printing it out. You will be emailed an electronic copy of this information upon submission.

Student Information
Student Name Student Name First Last
Certification Provider Information
Provider Name Provider Name First Last
Title
License/Certification Number and Issuing State
Provider Email
Provider Address Provider Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
FAX FAX - ### - ### ####
Professional
Date of Initial Contact with Student Date of Initial Contact with Student / MM / DD YYYY
Date of Most Recent Formal Contact/Appointment with Student Date of Most Recent Formal Contact/Appointment with Student / MM / DD YYYY
Approximate Frequency of Contact with Student since Initial Contact
Date of Completion of this Form Date of Completion of this Form / MM / DD YYYY
Student's DSM-5 diagnosis/diagnoses and diagnostic code(s):
Pertinent student history:
Onset of student's current diagnosed disability:
Summary of student's present symptoms:
Assessment procedures and evaluation instruments used in diagnosis:
Prognosis:
Is the student's condition currently stabilized?

Is the student's condition currently stabilized? Yes No
Please describe (especially if the student's condition is not stabilized):
Medication/Treatment Information
Describe the student's current medication needs and side effects and how the medication is expected to affect the student’s educational performance:
How long has the student been taking this medication?
Is the student still adjusting to or stabilized on the medication(s)?

Is the student still adjusting to or stabilized on the medication(s)? Still Adjusting Stabilized on Medication(s)
Please describe (especially if the student is still adjusting):
Information Supporting Accommodation Requests
Describe the student’s functional limitations in an educational setting.
Are there crisis episodes associated with the student's condition?
What recommendations do you have, if any, to equalize the student’s educational opportunities at the post-secondary level? (These may be services/accommodations related to exam administration, classroom or study activities, course requirements, or others.)
Has the student signed a release for you to share additional information with AccessibleNU staff?

Has the student signed a release for you to share additional information with AccessibleNU staff? Yes No
Certifying Authority
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY

Verification Form: Diagnosed Psychological Conditions

Verification Form: Diagnosed Psychological Conditions

Student Information

Certification Provider Information

Professional

Medication/Treatment Information

Information Supporting Accommodation Requests

Certifying Authority