PSYCHOLOGICAL DISABILITY DOCUMENTATION FORM
The student named below has requested services from the Office of Disability Services (ODS) at
Marquette University. In order to determine this student's eligibility for reasonable and appropriate
accommodations, we ask that you provide us current and comprehensive information attesting to the
student's disability and documenting the functional impact of the disability. The information you
provide will be kept in the student's confidential file in ODS.
In addition to the requested information sought from this form, please attach copies of any test results
or evaluations conducted as part of your diagnostic process.
Name of Student:
_______________________________________Birth Date: ___________________
1. Do you see this student on a regular basis? ____ Yes____ No
When was your last contact with this student? __________________________________________
2. What is your DSM-V diagnosis for this student?
3. Please check which of the skills listed below are substantially limited because of the student's
disorder.
* Substantially limited is defined as a "significant restriction in the condition, manner, or duration in
which a major life activity is performed compared to most people."
1) Time management
2) Organizational skills (physical and/or cognitive)
3) Task persistence
4) Memory skills
5) Reading (fluency, comprehension)
6) Quantitative skills
7) Written expression
8) Employment/work skills
9) Self esteem/social skills
10) Concentration
11) Other
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Office of Disability Services Marquette University P.O. Box 1881 Milwaukee, WI 53201
Phone: 414-288-1645 Fax: 414-288-5799
ODS 07/2014
4. What methods or testing instruments did you use to arrive at your diagnosis?
o
o
o
o
o
o
o
o
Structured or unstructured clinical interviews with the individual
Interviews with other individuals
Developmental history
Medical history
Neuropsychological / Psycho-educational testing
Date(s) of testing? ________________ Copy of testing results attached? ____Yes ____No
Standardized or non-standardized rating scales
Other (please specify)
5. Do you consider this student's disorder to be a disability?
____ Yes ____ No
6. What medications have been prescribed for this student?
Medication/dosage:
Date first prescribed:
If the student is on medication, what functional limitations does the student encounter?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
7. What accommodations do you recommend for this student?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
8. Will the student's disorder require absences from class? ____ Yes ____ No
If yes, please indicate the reason. *
_________ for symptoms experienced
_________ for side effects of medication or treatment
_________ for treatment of the disorder
* Please note - There may be limitations on the number of absences a student is allowed based on class
requirements.
9. Is there anything else you would like us to know about this student?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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Office of Disability Services Marquette University P.O. Box 1881 Milwaukee, WI 53201
Phone: 414-288-1645 Fax: 414-288-5799
ODS 07/2014
Please sign, date and return to our office. Thank you for your assistance.
______________________________________________
______________________
Signature of Treating Professional
Date
______________________________________________
______________________
Professional's Name (printed) and Title
License Number
______________________________________________
______________________
Telephone Number
______________________________________________
______________________
Address
Fax Number
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Office of Disability Services Marquette University P.O. Box 1881 Milwaukee, WI 53201
Phone: 414-288-1645 Fax: 414-288-5799
ODS 07/2014