Referred to Disability Advisor:
Accessibility Services
Confidential Information Form
Date: _______________________
Last Name:
________________________________________________________________
First Name: ________________________________________________________________
Student Number: __________________________ Age: ______ Gender:
Permanent/Sessional
Address: _________ __________________________________________________________
City: ________________________________________ Postal Code: __________________
University of Toronto Email Address:
_____________________________________________________________@utoronto.ca
_________________________________________________________@mail.utoronto.ca
(Please confirm that your University of Toronto e-mail address ends in either @utoronto.ca or @mail.utoronto.ca)
Telephone:
Type:
Phone Number:
Session(s):
May we leave a
message?
Primary
 Home  Work (_______)
 Cell  Pager
________________________
 Sessional
 Permanent
Yes No
 Name & phone # only.
Alternate
 Home  Work (_______)
 Cell  Pager
________________________
 Sessional
 Permanent
Yes No
 Name & phone # only.
Have you used our services before?
Yes No If yes, who was your primary contact_____________________________,
and when were you here? ________________________________.
What is your current status at the University of Toronto?
 Part-Time Student (0.5 to 2.5 courses)
 Full-Time Student (3.0 or more courses)
 Special Student
 Visiting Student
Undergraduate students: How many credits have you earned?
 0 - 3.5
 4.0 - 8.5
 9.0 -13.5
 14 or more
PLEASE COMPLETE OTHER SIDE OF PAGE
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Access Programs
 Academic Bridging Program
Professional Faculty
 Applied Science &
Engineering
 Architecture
 Dentistry
 Forestry
 Law
 Medicine
 Music
 Nursing
 Occupational Therapy
 OISE/UT
 Pharmacy
 Faculty of Kinesiology
and Physical Education
 Physical Therapy
 Radiation Science
 Rotman
 Social Work
 Toronto School of
Theology
 Transitional Year Program
 Special Student
________________________
St. George Campus
Undergraduate:
Arts & Science
 Innis College
 New College
 Saint Michael's College
 Trinity College
 University College
 Victoria University
 Woodsworth College
(See also Professional Faculty)
Degree:_________________
Program:________________
________________________
Graduate Studies:
Degree:
______________________
Program:
______________________
______________________
Stage in program:
 Course work
 Comprehensive
 Thesis
______________________
UTM/UTSC Undergraduate
You must first register with
Accessibility Services on your
home campus.
 Arts & Science UTM
 Arts & Science UTSC
______________________
International Student?
 Yes
 No
Degree:
____________________
With which areas do you need assistance?
 Chronic Health Problem (e.g. epilepsy/MS/MD/IBD/Cancer)
 Mobility/Functional Disability (e.g. CP/Polio/RSI)
 Mental Health Condition (e.g. Depression/Bipolar/Anxiety
Disorder/OCD)
 Learning Disability or ADHD
 Brain Injury with Mobility Effect
 Concussion
 Sensory Disability (e.g. Hearing/Vision)
 Temporary (Please describe):
______________________
 Other (Please describe):
______________________
For Office Use Only:
Registration YES  NO 
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Entered in Database 
THE INFORMATION ON THIS FORM IS CONFIDENTIAL.
IF YOU NEED ASSISTANCE COMPLETING THIS FORM, PLEASE ASK AT THE FRONT DESK.
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ACCESSIBILITY SERVICES
Initial Questionnaire for Students with
Mental Health Related Issues
If you require assistance completing this form or need it in alternative format, please ask at the front
desk.
Please answer the following questions as completely as possible. The information you provide will help
us to develop an accommodation plan that meets your individual needs.
1. What brings you to Accessibility Services at this time?
2. Who referred you to Accessibility Services?
3. When did you first register at the U of T? _____________________________
4. Did you recently (within 2 years) complete high school or studies at another educational
institution?
 Yes - please check one -  high school
 other
 No
If yes, please list any disability-related accommodations you received.
5. Please list adaptive technology and equipment you currently use to attend school and complete
your academic work: (i.e. CCTV, FM System, specialized software)
6. Have you applied for OSAP?
If yes, are you OSAP eligible?
 Yes
 Yes
 No
 No
7. Have you ever been on academic probation or suspension?
If yes, please provide details.
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 Yes  No
8. What are your reasons for attending the University of Toronto? What are your
academic/career/life goals?
9. What is your health disability?
10. Is your disability: (please check one):
 Permanent
 Progressive
 Temporary
11. Please list your current medications and any side effects, if any:
12. Have you ever had a head injury?
 Yes  No
If yes, please list the year the injury occurred
13. Has anyone ever told you that you may have a learning disability?
 Yes  No
14. What challenges does your disability pose for you at university? For first year students, what
challenges did your disability pose for you during high school?
15. How has your disability affected your schoolwork in the past month? Are you up to date in
readings and assignments?
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16. How many hours a week do you spend:
 Studying
# ____hours
 Paying job
# ____hours
Please feel free to write any additional comments or questions:
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Accessibility Services
Confidentiality and Consent to Share Information Agreement
In order to provide good service Accessibility Services wants students to have trust and confidence in how your information
will be used and shared. Staff employed by Accessibility Services regards information we learn about students in
interviews, personal communications and/or reports from other professionals as confidential as required by law. We only
convey information about the impact of your disability on your learning or your daily needs while on campus with your
permission. The level of information provided is on a need to know basis meaning that only pertinent information relevant
to the current request is shared. Your consent may be withdrawn at any time by informing your disability counsellor in
writing.
As required by law, Accessibility Services staff will reveal information when:




There is a suspicion of child abuse
A student poses a significant danger to themselves or others
A student reports sexual abuse by a health care professional
It is legally required, for example by subpoena, summons or court order
1. Please read and provide your written consent below:
 I give permission for my disability counselor to view my academic records on ROSI
 I understand that test/exam accommodations will be shared with Test and Exam Services at the Office of Space
Management.
2. In addition to necessary sharing of information among staff at Accessibility Services, I consent to the release and
sharing of information with the following:
Initial all that apply:
____ My Registrar at __________________ College
____ Professors in courses I am registered in at U of T
____ Student Health Services
____ Counselling and Psychological Services
____ Academic Progress Team
____ Other _____________________ please specify
Signature __________________________ Date ________________
Witness ___________________________ Date _________________
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UNIVERSITY OF TORONTO
ACCESSIBILITY SERVICES
455 Spadina Avenue, 4th Floor, Suite 400, Toronto, Ontario, M5S 2G8
Tel: 416-978-8060
Fax: 416-978-5729
TTY: 416-978-1902
Documentation for Students with Mental Health Related Disabilities
To receive support from Accessibility Services a student must “communicate his or her needs in sufficient detail
and co-operate in consultations to enable the person responsible for accommodation to respond to the request.”
(Ontario Human Rights Code Guidelines, 1994, p.17). The OHRC Guidelines (1994) also note that the university,
as the body responsible for accommodating, must have sufficient information “to properly assess the impact of the
disability on the specific academic task and know how to make the requested accommodation.”
In order to be accommodated, a student who registers with Accessibility Services with mental health- related
disabilities must provide sufficient documentation to verify disability and its functional impact on the student’s
academic performance.
Documentation must be provided by a practitioner who is certified in the area specific to the disability (e.g., a
psychiatrist, registered psychologist or family physician/general practitioner).
This student is requesting disability-related supports and accommodations while studying at the University of
Toronto. In addition, this medical documentation may be used to access financial funds through the Bursary for
Students with Disabilities and the Canadian Grant for Students with Permanent Disabilities. The student is
required to provide the University with documentation that:

Is provided by a licensed health-care professional, qualified in the appropriate specialty
Provides detailed documentation, evidence of assessment, and sufficient explanation to
support the accommodations being considered or requested.
Note: A diagnosis alone does not automatically mean disability-related accommodation is required.
The provision of all reasonable accommodations and services is assessed based on the current impact of the
disability on academic performance. Generally, this means that a diagnostic evaluation or re-assessment has
been completed within the last year.
CONFIDENTIALITY
Collection, use, and disclosure of this information are subject to all applicable privacy legislation.
TO BE COMPLETED BY A REGULATED HEALTH PRACTITIONER QUALIFIED IN THE APPROPRIATE
SPECIALTY.
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MEDICAL CERTIFICATE for MENTAL HEALTH RELATED ISSUES
Patient’s Name:
Patient’s University of Toronto Student Number:
Date of Birth:
Last date of Clinical Assessment:
A. DIAGNOSIS AND CONCURRENT CONDITIONS

Please provide a clear diagnostic statement, avoiding such terms as “suggests” or “is
indicative of.”
If the diagnostic criteria are not present, this must be stated in the report.
Please note any multiple diagnoses or concurrent conditions.
1. Primary Mental Health Disability: (a DSM IV; DSM V; ICD-10 diagnosis):
2. Secondary Mental Health Disability: (a DSM IV; DSM V; ICD-10 diagnosis):
3. Additional / Other:
B. MEDICATION(S)
[ ] Not applicable
1. Brand/Generic Name and dosage (list all):
2. Describe potential side effects of medication(s) that impact academic performance:
C. CURRENT TREATMENT (counseling, psychotherapy, acupuncture, massage therapy, etc.)
1. Description of current treatment:
2. How long have you been treating this patient?
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D. IMPACTS ON ACADEMIC FUNCTIONING (please specify where possible)
[ ] Energy level (please specify impact e.g. fluctuating):
[ ] Impact on sleeping cycles:
[ ] Ability to manage full academic work load:
E. COGNITIVE IMPACTS:
[ ] Attention and Concentration
[ ] Communication
[ ] Information processing (written and verbal)
[ ] Memory
[ ] Organization and time management
[ ] Social interactions
[ ] Stress management
[ ] Other/comments:
F. RECOMMENDED ACCOMMODATIONS
Please list recommendations below. The disability counsellor will discuss the recommendations with the student.
Accommodations will be put in place that are in line with sufficient/proper documentation and following discussion
between the student and his/her disability counsellor.
[ ] Test/ Exam Accommodations (may include considerations related to time, space, equipment and/or
environment modifications)
Specify:
[ ] Adaptive Technology Assessment is recommended (the student presents with cognitive/ physical/ motor
and/or health difficulties that warrant further assessment for possible adaptive equipment to assist with academic
studies)
[ ] Other Recommendations (please indicate any that apply): e.g., light box, counselling, massage therapy;
yoga/meditation; ergonomic furniture; physiotherapy
[ ] Other (please specify):
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G. STATEMENT OF DISABILITY
Please indicate the appropriate statement for this student in the current academic setting: (check box for
either permanent or temporary disability):
[ ] PERMANENT DISABILITY
Identification/designation of a permanent disability is usually determined after considerable assessment, treatment
and/or observation of the patient. A permanent disability involves on-going (chronic or episodic) symptoms (that
will significantly impact the student over the course of his/her academic career). To designate a permanent
disability, an evaluation has been conducted that involved the use of assessment tools/techniques that
examined the functional impact of the disability as well as the permanence of the observed/assessed
limitations. Multiple visits and observations of the patient in addition to review of pertinent medical
history documentation are necessary to determine permanence of a disability. Typical examples of a
permanent disability include (but are not limited to): neurodevelopmental disorders (e.g., ADHD, learning
disability, autism spectrum disorder); chronic health conditions (e.g., diabetes, epilepsy); sensory disorders (e.g.,
deafness, low vision,); mobility impairments (e.g., cerebral palsy, paraplegia, arthritis); and, chronic mental health
conditions (e.g., dysthymia, bipolar disorder, persistent Generalized Anxiety Disorder).
Students with documentation that identifies a permanent disability may be able to access funds/fee adjustments
from government assistance programs including but not limited to OSAP as well as other accommodations. In
evaluating permanence of a disability, for OSAP purposes, the Canadian Student Loan program defines a
permanent disability as “a functional limitation caused by a physical or mental impairment that restricts the ability”
of a student “to perform the daily activities necessary to participate in studies at a post-secondary level or the
labour force and is expected to remain with a student for his/her “expected life”. (DD. Gov. of Can. Section 4.5,
2003)
[ ] TEMPORARY DISABILITY
A disability is designated as temporary in the following situations:
The disability will only last for a determined period of time. Indicate the time period outlining duration
from
/
/
to
/
/
(Year, Month, and Day)
*If unknown, please indicate reasonable duration for which s/he should be accommodated/supported at
this time (please specify number of weeks/months):
THE ABOVE SECTION MUST BE COMPLETED if indicating the disability is Temporary. Accommodations
will not be extended beyond dates listed above without updated documentation prior to the expiry date of the
temporary disability listed above.
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Typical examples of a temporary disability include (but are not limited to): orthopedic injuries (e.g., broken leg,
injured back, concussions/mild TBIs, initial episode of a mental health condition, surgical recovery, serious
infections).
A temporary disability certificate has a maximum duration of 6 months. Should the period of disability still be active
beyond this point, a new certificate is required.
Or
The disability is currently under review/still being assessed and sufficient assessment and observation of the
patient has not been completed yet to allow determination of the permanence of temporary nature of the disability.
When the diagnosis is still being considered (i.e. it is a “working diagnosis”), designate the disability as temporary.
When the assessment is complete, provide updated documentation as to whether the disability remains temporary
or can now be listed as permanent.
H. HEALTH CARE PRACTITIONER INFORMATION
Name of Health Practitioner:
Specialty: [ ] Psychiatrist [ ] Psychologist [ ] Other:
Health Practitioner Signature:
License / Registration No.:
Facility Name and Address:
Date:
Note: If you do not have an office stamp please sign and attach your letterhead – signatures on
prescription pads will NOT be accepted
Please use office stamp.
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UNIVERSITY OF TORONTO
ACCESSIBILITY SERVICES
455 Spadina Avenue, 4th Floor, Suite 400, Toronto, Ontario, M5S 2G8
Tel: 416-978-8060
Fax: 416-978-5729
TTY: 416-978-1902
RELEASE OF INFORMATION
TO BE COMPLETED BY STUDENT:
I, __________________________________________, hereby authorize the above named professional to
provide the following information to Accessibility Services at the University of Toronto and if required to supply
additional information relating to the provision of my academic accommodations and disability-related services. I
also authorize Accessibility Services to contact the physician to discuss the provision of accommodations.
Student’s Signature: ___________________________________________________
University of Toronto Student Number: _____________________________________
Date: ________________________________________________________________
Thank you for taking the time to complete this form.
The information will facilitate the supports requested by your patient while at the
University of Toronto.
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