Request for Documentation
Psychological Disabilities
This questionnaire will provide current documentation to be used to determine eligibility
for reasonable and appropriate accommodations to students requesting such services.
Release of Information
I ____________________________ authorize the release of the following information to
______________________________ at Rose-Hulman Institute of Technology.
Student signature: ______________________________________________________
Date: ________________________________________________________________
To be completed by the treating or diagnosing professional/s.
1.
Diagnosis, date of diagnosis, and last contact with the student.
2. History: presenting symptoms; duration and severity of disorder; relevant
developmental and historical data.
3. A description of current functional limitations in the academic environment as
well as other settings.
4. Recommendations: Regarding accommodations, with rationale.
5. Medications prescribed ____________________________________
Amount and frequency
Response to medication and frequency of monitoring
6. Any indication of an additional diagnosis such as depression, bi-polar, or anxiety?
Have you ever recommended any type of therapy?
Please include any information on learning disability testing, intellectual functioning
and/or other academic problems which you feel we should know in order to provide
appropriate accommodation for this student.
Thank you for your help.
Signature:
_____________________________________________________
Name and title:
(Print)
_____________________________________________________
Address:
_____________________________________________________
_____________________________________________________
Phone:
_____________________________________________________
Date:
_____________________________________________________
Please mail form to:
Karen DeGrange
Rose-Hulman Institute of Technology
5500 Wabash Avenue, CM 39
Terre Haute, IN 47803