Request for Documentation Psychological Disabilities

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.
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.
Name and title:
Please mail form to:
Karen DeGrange
Rose-Hulman Institute of Technology
5500 Wabash Avenue, CM 39
Terre Haute, IN 47803