CUA by hedongchenchen

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									                                           CUA


                  THE CATHOLIC UNIVERSITY OF AMERICA
                         OFFICE OF DISABILITY SUPPORT SERVICES
                                 WASHINGTON, DC 20064
                                     202-319-5211
                                   FAX 202-319-5126


                                   Psychological Certification Form

                                   To Be Completed by the Student

Student’s Name:______________________________________              Student’s ID: _________________

Student’s E-Mail: ____________________________________             Student’s Phone: ______________

Today’s Date:_______________________

                           To Be Completed by the Student’s Evaluator
1) DSM IV Diagnosis:
Axis I: ____________________________________________________________________________
Axis II: ____________________________________________________________________________
Axis III: ___________________________________________________________________________
Axis IV: ___________________________________________________________________________
Axis V (GAF scores): ________________________________________________________________

2) Date of Diagnosis:________________________________

3) In addition to the 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:

X Criteria                                       Notes
   Structured or Unstructured interviews

   Interviews with other persons

   Behavioral Observations

   Developmental History

   Educational History

   Medical History
       Neuro-psychological testing. Dates:

       Psycho-educational testing. Dates:

       Standardized or nonstandardized rating scales

       Other (please specify)




    4) This student has been under a physician’s care for this issue since: _________________________
    5) Date student was last seen: ______________________________
    6) How long is this condition likely to persist ______________________________________
    7) How often is the student required to check-in with a physician?
    Once a week        Once a month       Every three-four months   Every six months
    Once a year       As needed           Other:______________________
    8) Is the student currently taking medication(s) for these symptoms?    YES       NO
    If yes, what medications is the student currently taking? For each medication, describe the side effects
    and any impact on academic performance. Do limitations/symptoms persist even with medications?

Medication and Dosage           Side Effects          Academic Impact           Persistence of Symptoms




    9) Please check which of the major life activities listed below are affected because of the psychological
    diagnosis. Please indicate the level of limitation.

                                        NO IMPACT MODERATE IMPACT       SUBSTANTIAL IMPACT     DON’T KNOW
Concentrating
Memory
Sleeping
Eating
Social Interactions
Self-care
Managing internal distractions
Managing external distractions
Timely submission of assignments
Attending class regularly and on-time
Making and keeping appointments
Stress Management
Organization
10) What other specific symptoms manifesting themselves at this time might affect the student’s
academic performance?
__________________________________________________________________________________
__________________________________________________________________________________
11) What is the student’s prognosis?
__________________________________________________________________________________
__________________________________________________________________________________

12) How long do you anticipate that the student’s academic achievement will be impacted by his/her
disability?

Circle one:    6 months        1 year   1-2 years    on-going     permanent        unknown

13) Is there anything else you think we should know about the student’s psychological disability?
__________________________________________________________________________________
__________________________________________________________________________________

Name/Title ___________________________________________________________________
Signature______________________________________________________________________
License/Certification #_____________________________ State ___________________________
Address _______________________________________________________________________
City, State, Zip Code_____________________________________________________________
Phone ___________________________ Fax ____________________________
Qualified diagnosing professionals are licensed psychologists, psychiatrists and neurologists. The
diagnosing professional must have expertise in the differential diagnosis of the documented mental
disorder or condition and follow established practices in the field.


Send all documentation to:
                                 Disability Support Services
                             The Catholic University of America
                                   620 Michigan Ave NE
                                    207 Pryzbyla Center
                                  Washington, DC 20064
                                    202-319-5211 Phone
                                     202-319-5126 Fax
                                     http://dss.cua.edu/




5/28/09

								
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