DISABILITY VERIFICATION

Psychological & Psychiatric Disabilities

(to be completed by diagnosing/current psychiatrist or psychologist)

Please read the following prior to completing this form:

The Office of Student Access Services at Malone provides support services to students with diagnosed disabilities, including psychological and psychiatric disabilities. To ensure the provision of reasonable and appropriate accommodations for our students, this office requires current and comprehensive documentation of the disorder from their diagnosing/current physician. This should include information that describes the symptoms of the disorder, medication prescribed, and recommendations for treatment.

Please note that eligibility for services is determined based on a review of this information, in accordance with criteria established in the codification of Section 504 of the Rehabilitation Act of1973, and in cases pertaining to the Americans with Disabilities Act. It is therefore imperative that comprehensive information be provided so that Malone can make an appropriate determination about the student's eligibility to receive disability-related accommodations under the law. Confidentiality of the information provided is ensured, and will in no way become part of the student's academic record. Please feel free to contact the Office of Student Access with any questions or concerns you might have regarding the information you are being asked to provide. Thank you for your assistance.

Please provide the following information about: _____________________________________________

1. DSM-IV Diagnosis: _______________________________________________________________

Date of Diagnosis: ________________________________________________________________

Last contact with student: ___________________________________________________________

2. Describe the symptoms associated with this disorder and the student�s prognosis:

___________________________________________________________________________________

3. Describe how this disorder may affect this student in Malone's academic environment:

___________________________________________________________________________________

4. List current medication, dosage, frequency and possible adverse side effects:

___________________________________________________________________________________

5. List any recommendations for accommodations in an academic setting that you have for this student (i.e. extra time on tests, distraction-free testing space, etc.): __________________________

___________________________________________________________________________________

6. Describe any specific concerns you may have, or other ways that we may be of further assistance to this student: _____________________________________________________________________

___________________________________________________________________________________

Psychiatrist/Psychologist Signature: _________________________________________________

Date: ___________________________________________________

Printed Name and Title: ___________________________________________________________

Address: ______________________________________________________________________

____________________________________________________________________________

Phone: ( ) ___________________________________________

E-mail address (if applicable): ________________________________

Please mail or fax this form to:

Malone's Office of Student Access

515 25^th Street NW

Canton, OH 44709

Phone: 330/471-8496

Fax: 330/471-8149