Verification Form for Students with
Psychiatric/Emotional Disabilities
(Professional Provider Form)
Students requesting support services under laws pertaining to non-discrimination for individuals with
disabilities such as the Americans with Disabilities Act (ADA), Section 504 of the Rehabilitation Act of
1973 and the Fair Housing Act are required to submit documentation to verify their eligibility for services
and accommodations. This documentation must indicate evidence that the disability substantially limits a
major life activity. The provision of "all reasonable accommodations" is based on the current impact of
the disability on academic performance. Thorough documentation is needed to help determine the
reasonable and appropriate accommodations that the student is qualified to receive. Therefore, it is in the
student's best interest to provide recent and appropriate documentation (Must be within the past 3-6
months).
The Campus Access Services office (CAS) at the University of New Haven strives to ensure that qualified
students with psychiatric disabilities are accommodated and, if possible, to see that these accommodations
do not jeopardize successful therapeutic interventions. It should be noted that academic accommodations
are intended to ensure access to educational opportunities for students with disabilities. The mandate to
provide reasonable accommodations does not extend to adjustments that would "fundamentally alter" the
nature of the course, course components, or course requirements.
The student named below is requesting an accommodation due to their psychiatric disability. So as to
ensure that this accommodation request be considered, CAS requires that this form be completed by a
qualified professional who has first-hand knowledge of the student's condition and is an impartial
individual not related to the student.
Professional Information (This section is to be completed by a qualified Professional)
Student:
Date of Completion of Form:
Name of Certifying Professional:
Name of Agency:
Address:
City:
Phone:
State:
Zip Code:
Fax:
Professional Title:
License/Certification Number and Issuing State:
Date of Initial Contact with Student:
Date of Last Contact with Student:
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Diagnostic Assessment
Please attach a copy of any diagnostic report, psychoeducational assessment or neuropsychological
evaluation associated with this case.
Primary Diagnosis (include name and DSM-V):
Date of Diagnosis:
Diagnostic Information
If psychological instruments were used, please identify the instrument(s) used and the interpretation that
supports the diagnosis of the disorder and its severity. (Use attachments as required.)
What are the recommended therapeutic interventions?
If an emotional support animal (ESA) is a recommended therapeutic intervention, please indicate the
student’s functional limitation(s) and severity of the limitation(s) that are supported by the animal.
In Comments, please indicate what the animal does that makes the student more functional.
Functional Limitation
Caring for oneself
√
Mild
Moderate
Severe Comments
Performing manual
tasks
Sleeping
Eating
Speaking
Learning
Reading
Concentrating
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Thinking
Communicating
Other
Please indicate below which of the above functional limitations impact the student’s ability to fully enjoy
his/her living space?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What is the current compliance with and progress from the therapeutic intervention(s)?
What is the history of hospitalization related to this condition?
Does this person currently pose a threat to him/herself or others? If so, please specify in what ways.
Treatment Information
Medications
If applicable, what are the current medications used (including dosage and side effects)?:
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If applicable, what is the long-term medication plan?:
If applicable, what is the current compliance with the medication plan?:
If applicable, what is the prognosis for the medication plan? (Include likelihood of improvement or
further deterioration and within what approximate time frame.):
Impact of Condition on Educational Success
What are the learning abilities specific to the post-secondary environment that are impaired by the
psychiatric disability? (e.g., difficulty with concentration, slow processing speed, etc.):
Are there implications for taking exams and other classroom activities that are caused by the disorder or
medications? Please specify which:
Suggested Accommodations
NOTE:
Final determination of appropriate reasonable accommodations will be determined by CAS in accordance
with the mandates of the Rehabilitation Act of 1973 and the Americans with Disabilities Act as well as court rulings
and Department of Education Office of Civil Rights rulings related to these two laws. Each recommended
accommodation must be accompanied by an explanation of its relevance to the diagnosed disability.
What academic adjustments are suggested for this student? Each recommended adjustment should include a
detailed explanation of its relevance to the disorder that is diagnosed. The evaluator also should indicate the level of
impaired functioning at which the individual is currently performing even with the benefits of treatment. (For
instance, with a person diagnosed as having a major depression but whose functioning is significantly improved with ongoing
drug therapy, the evaluator should indicate at what % level of “normal” functioning the person is currently operating.)
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Suggested Accommodations (Continued) Please list below:
Signature of Certification
I certify that this information is true, accurate, and complete.
Signature of Certifying Professional
Date
This document may not be released without written permission from the student or by order of a court. It
will be destroyed seven years after the student is no longer enrolled. The student will have access to this
document but you may specify that this access be given only when a person qualified to explain the
document is available.
Check ONE:
Student access
OR Student Access only with qualified professional
Thank you for your assistance in completing this form
If you have any questions regarding the nature of this information needed for students with disabilities, please call
the Campus Access Services office at (203) 932-7332, Mon. through Fri. from 8:30 A.M. to 4:30 P.M.
This form should be returned to:
University of New Haven
Campus Access Services
300 Boston Post Road
West Haven, CT 06514
Confidential Fax: (203) 931-6082
Email: campusaccess@newhaven.edu
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