New Hanover County Schools
Medical/Psychological Statement of Diagnosis
Section 504
All three (3) sections must be completed for ALL STUDENTS.
The following information will be reviewed by the Section 504 Team and considered during eligibility and planning
meetings.
1. To Be Completed by Parent/Guardian (Prior to being given to Physician or Appropriately Trained and/or
Licensed Health Professional):
Name of Student
School:
Grade:
Phone #:
Parent/Guardian(s):
DOB:
Fax #:_____________________
Phone #:____________________________________
Address:
Parent Consent: New Hanover County Schools has my permission to receive medical information from the attending
physician or other appropriately trained and/or licensed health professionals for my child to be considered for services.
**(Parent/Guardian/Student at Age of Majority) Signature: ____________________________________________
2. Diagnosis: To be completed by the treatment professional:
Date of Exam: ______________________
Medical Diagnosis: _______________________________________________________________________________
Psychological Diagnosis: __________________________________________________________________________
3. Response to diagnosis: To be completed by the treatment professional, and additional information may be
added on the back:
Impact of the medical condition in the school setting. List any specific restrictions or supports that may benefit this
student. If none, state so.
Printed and signed name of Physician/Appropriately Trained and/or Licensed Health Professional:
_______________________________________/______________________________________
Date: ________________
Phone : _________________________________Fax: ________________________________
Email: ________________________________________
www.NHCS.net • 6410 Carolina Beach Road • Wilmington, NC 28412 • 910-254-4454 • Fax 910-254-4446 • Kristin.jackson@nhcs.net