UNIVERSITY OF WISCONSIN-MILWAUKEE

Student Accessibility Center
Mitchell Hall, Room 112, P.O. Box 413,  Milwaukee WI 53201
Tel: (414) 229-6287          Fax: (414) 229-2237

CERTIFICATION OF PSYCHOLOGICAL DISABILITY

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?

  4. Axis I:
    Axis II:
    Axis III:
    Axis IV:
    Axis V:

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

    Date first prescribed:

  7. 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.

  8. checkboxStructured or unstructured clinical interviews with the individual
    checkboxInterviews with other individuals
    checkboxDevelopmental history
    checkboxMedical history
    checkboxPsychological testing - Date(s) of testing?
    checkboxStandardized or non-standardized rating scales
    checkboxOther (please specify)

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

  10. 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
  1. Please describe the functional limitations this student encounters when using medication.



  1. Please describe an appropriate intervention plan and indicate how the plan will be managed:
    Treatment/Intervention
    Provide
    Needs Referral
    • Pharmacotherapy
    checkbox checkbox
    • Compensitory strategies (please specify)
    checkbox checkbox
    • Academic study skills (please specify)
    checkbox checkbox
    • Brief psychotherapy
    checkbox checkbox
    • Long-term psychotherapy
    checkbox checkbox
    • Other
    checkbox checkbox

  2. Please indicate which accommodations, if any, may be beneficial to this student.
checkbox  Distraction free test environment
checkbox  Extended test time
checkbox  Notetaking support
checkbox  Reduced credit load
checkbox  Other
  1. 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.