The student named below has applied for services from the Student Accessibility Center (SAC) at UWM. In order to provide reasonable and appropriate services for students with psychological disabilities, current and comprehensive information documenting the functional impact of the disability is required. This form is intended to assist clinicians in providing sufficient information so that eligibility for services can be determined. The information you provide will not become part of the student’s educational records and will be kept in the student’s confidential file at SAC. In addition to the requested information, please attach any additional information; for example, your report and any test results. Thank you for your assistance.

1. Name of Student:                                                                                       Today's Date:                          
   



2. Date of your last contact with student:                                    



3. What is your DSM-IV multi-axial diagnosis for this student?

Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:


4. Please indicate medications that have been prescribed for this student.
Medication(s)/dosage:

Date first prescribed:


5. What methods  or testing instruments did you use to arrive at your diagnosis?  Please check all relevant items adding brief notes that you think might be helpful to us as we determine which acommodations services are appropriate for the student.

Structured or unstructured clinical interviews with the individual
Interviews with other individuals
Developmental history
Medical history
Psychological testing - Date(s) of testing?
Standardized or non-standardized rating scales
Other (please specify)


6. Please assess degree of functional impairment demonstrated by your patient:

1 = Negligible     2 = Moderate     3 = Substantial     4 = Severe     5 = Unknown     (circle one)

1)  Time management	1	2	3	4	UN
2)  Organizational skills (physical and/or cognitive)	1	2	3	4	UN
3)  Task persistence	1	2	3	4	UN
4)  Memory skills	1	2	3	4	UN
5)  Reading (fluency, comprehension)	1	2	3	4	UN
6)  Quantitative skills	1	2	3	4	UN
7)  Written expression	1	2	3	4	UN
8)  Employment/work skills	1	2	3	4	UN
9)  Self esteem/social skills	1	2	3	4	UN
10)  Other	1	2	3	4	UN

8. Please describe the functional limitations this student encounters when using medication.

9. Please describe an appropriate intervention plan and indicate how the plan will be managed:

   Treatment/Intervention	Provide	Needs Referral
   Pharmacotherapy
   Compensitory strategies (please specify)
   Academic study skills (please specify)
   Brief psychotherapy
   Long-term psychotherapy
   Other

   
   
10. Please indicate which accommodations, if any, may be beneficial to this student.

11. Is there anything else you would like us to know about this student?

                                                                                                                                  
Signature of Professional                                                                         Date

                                                                                                                                   
Professional's Name (printed) and Title                                                   License No.

                                                                                                                                   
                                                                                                               Telephone No.

                                                                                                                                    
Address                                                                                                    Fax No.