OFFICE OF DISABILITIES SUPPORT SERVICES
240 Academy Street, Alison Hall, Suite 130
Newark, Delaware 19716
(302) 831-4643
DSSoffice@udel.edu
Certification of Psychological Disability
The student named below has applied for services from the Office of Disability Support Services.
In order for DSS to establish whether this student has a disability and to determine his/her eligibility
for services, we will need your assessment and diagnosis of the student. A disability is defined as a
physical or mental impairment that limits one or more major life activity such as those delineated
below. You can fax or mail the form to us at the address listed on this form. If you prefer, you can
answer these questions in a signed and dated letter on your professional letterhead.
All contact information and documentation received is kept in a separate, private file within the Office
of Disability Support Services. No information concerning inquiries about accommodations or the
documentation will be released/discussed without written consent from the individual requesting
accommodation/s. This information is released/discussed on a need-to-know basis and is subject
to FERPA.
Documentation is used to evaluate requests for accommodations or auxiliary aids. The evaluation
process includes a review of the documentation and how a request for accommodations interfaces
with the fundamental goals and essential standards of the program, course, and service or benefit in
question.
Student’s Name:_______________________________________________
Date: ____________________
1. What is the DSM-5 diagnosis of the student? (include any relevant specifiers and
subtypes)
2. Date of above diagnosis?
3. Date student was last seen?
4. If the student is currently undergoing treatment, please describe the
treatment and how treatment may affect the student in a post-secondary
setting.
5. Medications, effects, and possible side-effects:
6. Major Life Activities Assessment: Please check which of the major life
activities listed below are affected because of the impairment. Please
indicate level of limitation.
Life Activity
Sleeping
Eating
Reading
Learning
Concentrating
Memorizing
Thinking
Expressive Skills
Receptive Skills
Handwriting
Social Interaction
Communicating with Others
Caring for oneself
Activities of Daily Living
Stress Management
Managing Anxiety
Managing internal distractions
Managing external distractions
Other
Negligible
Moderate
Substantial
Don’t know
7. What are the specific functional limitations resulting from the impairment’s
impact on the major life activities identified above?
8. Are the functional limitations permanent? If not, what is the expected
timeline for resolution?
Certifying Medical Professional:
Signature of Medical Professional
Printed Name and Title
Address
City, State, Zip code
Date
License #
Telephone #
Fax #