LEARNING
NEEDS AND
VERIFICATION OF PSYCHIATRIC CONDITION OR DISABILITY
I, the undersigned, certify that:
Name of Student: _______________________________________________
SSN#: _______________________________________________________
Address: _____________________________________________________
_____________________________________________________
Please mark the most appropriate description for this individual:
[ ] meets the definition for a psychiatric disability as defined by ADA and Section 504 by reason of the following limitation.
[ ] has a medical condition for which academic accommodations may be appropriate.
1. Diagnosis/Description of Psychiatric Condition or Primary
Disability (use DSM-IV criteria and code):
2. Functional Limitations (e.g., mood lability; difficulties with attention, memory, or
expression):
3. Date the diagnosis was formally established?
4. Current Treatment(s)/Therapy and Prescribed Medications and Dosage:
5. The psychiatric condition or disability above is:
[ ] Permanent/Chronic
[ ] Temporary – 6 months or less
[ ] Short term / Temporary – (expected duration:
___________)
5. The condition or disability is: [ ]
Observable [ ] Not
Observable
6. Please list special assistance you recommend:
Complete records are on file at the below location and will be available
upon request (release attached).
Signature
Date
Name (please print)
Title
Name of Agency
Phone
Street
City/State/Zip
Please return to:
Director, Learning Needs and Evaluation Center
Elson Student Health Center
400 Brandon Avenue
PO Box 800760
Charlottesville, VA 22908-0760
Phone: (804) 243-5180
Fax: (804) 243-5188