Psychiatric by pghr43eN


									                      OFFICE FOR STUDENTS WITH DISABILITIES

STUDENT’S NAME: ____________________________________________________________________________
DATE OF BIRTH: ____________________              CLC ID#:________________              DATE: _________________
CITY/STATE/ZIP: ________________________________________TELEPHONE #:_________________________

Permission is given to the Office for Students with Disabilities to receive details of my disability, as specified
            below, for the purpose of determining appropriate and reasonable accommodations.

Student Signature: _____________________________________________________________________________

To: Mental Health Professional (Licensed Psychologist/Psychiatrist/Licensed Clinical Social

The above-named student has applied for academic accommodations available to qualified individuals with
disabilities through the Office for Students with Disabilities at the College of Lake County.

Current and comprehensive documentation (generally within 3 years) of the student’s disability must be on file in
the Office for Students with Disabilities to determine appropriate and reasonable accommodations prior to a
student receiving academic accommodations. Any school plan (e.g., Individualized Education Program, 504
Plan, or Summary of Performance) is not sufficient in and of itself, but it may be included.

The information you provide is considered confidential information and is not shared with any other entity
without the student’s permission and does not become part of the student’s educational records. The student
has indicated that you can provide documentation of disability, along with information pertinent to functioning in

Please address the criteria outlined below in a typed report on professional letterhead. Please fax
(847-543-3474) or mail the information requested to the Office for Students with Disabilities.

Contact our office at 847-543-2055 for further information regarding this request

Please note: documentation requirements for standardized tests (GED, ACT, HOBET, etc…) may differ. Student
needs to discuss individual testing needs with an OSD staff member.

                                Criteria for Documenting Psychiatric Disabilities

    1.   A clear statement of the DSM-IV-TR diagnosis, including pertinent history.
    2.   Date of diagnosis.
    3.   Date of last clinical contact.
    4.   A narrative summary of assessment procedures performed, including all scores used to make the
    5.   A summary of how the disability substantially limits one or more life functions.
    6.   A statement that determines if the disability is permanent or will change over time.
    7.   A description of present symptoms, fluctuating conditions/symptoms, and any medications and their
    8.   A statement of how the disability affects the student in an academic environment. Outline recommended
         reasonable accommodations supported by the diagnosis. Include detailed explanations as to why
         accommodation is needed and supported by testing data.
    9.   Signature, name, title, specialty, and license/certification number of the professional preparing the

                                                                                    Psychiatric Documentation: Revised 3/18/08
19351 W. Washington St., Grayslake, IL 60030

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