Student Accessibility Services

DISABILITY VERIFICATION

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

Student Accessibility Services at Kent State University 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 psychiatrist or psychologist. This should include information which 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 of 1973, and in case precedent pertaining to the Americans with Disabilities Act. It is therefore imperative that comprehensive information be provided so that Kent State Accommodations Specialists 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 Student Accessibility Services office with any questions or concerns you might have regarding the information you are being asked to provide. Thank you for your assistance.

Name of Student: ____________________________________________

1. DSMV-IV Diagnosis____________________________________________________________

Date of Diagnosis_______________________________________________________________

Last contact with student:__________________________________________________________

2. Describe the symptoms associated with this disorder:

______________________________________________________________________________

3. Describe how this disorder may affect this student in the college academic environment:

______________________________________________________________________________

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

______________________________________________________________________________

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

______________________________________________________________________________

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

______________________________________________________________________________

Psychiatrist/Psychologist Signature:____________________________ Date:_________________

Printed Name and Title:___________________________________________________________

Address:______________________________________________________________________

City:_______________________ State:_____________________ Zip:_____________________

Phone: ( _____) ________________________________

Please return this form to:

Student Accessibility Services
Kent State University
Ground Floor DeWeese Center
Kent, Ohio 44242-0001

Phone: 330-672-3391
Fax: 330-672-3763

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

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