Download Disability Support Services

Disability Support Services
Montana State University Billings
1500 University Drive
Billings, MT 59101
(406) 657-2283
(406) 545-2518 VP
(406) 657-1658 Fax
[email protected]
City College
3803 Central Avenue
Billings, MT 59102
(406) 247-3029
(406) 545-1026 VP
DISABILITY VERIFICATION FORM TO BE COMPLETED BY LICENSED PROFESSIONAL
(LD, ADD/HD, Psychological, etc.)
The student named below may be eligible for services offered through this office. In order to
provide these services, we must have verification of the student’s disability.
Please note: The determination of actual services and accommodations will be made
by Disability Support Services.
To be completed by STUDENT (please print legibly in ink):
Student’s Name: ________________________________________________
Last
First
Middle
Social Security #: _____________________Date of Birth: __________
I authorize the release of information requested below to Disability Support Services at
Montana State University-Billings. (Your evaluator may have additional releases for you to
sign.)
________________________________________________________________
Student’s Release Signature
Date
To be completed by a licensed/certified PROFESSIONAL:
1.
Diagnosis: ________________________________________________________
2.
Multiaxial DSM IV classification(s):
Axis I: __________________________________________________
Axis II: __________________________________________________
Axis III: _________________________________________________
Axis IV: _________________________________________________
3.
Level of severity: _____Mild _____Moderate ____Severe ____Partial Remission
4.
Date(s) of diagnosis: ________________________________________________
5.
Date of last office visit: ______________________________________________
6.
How does the student’s disability substantially limit his/her ability to function in an
academic environment (i.e., classroom activities, test taking, memory or perception,
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etc.--not paying attention and boredom are NOT acceptable examples of substantial
limitations on functioning):
___________________________________________________________________
___________________________________________________________________
7.
Current prescribed medications related to disability:
Medication
Effects/side effects
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
8.
What are some accommodations that will help the student with tasks such as reading,
taking tests, note taking, etc.?
______________________________________________________________________
______________________________________________________________________
Please include a psychological evaluation or psycho-educational evaluation for LD &
AD/HD.
Attached report must include the following:
 Assessment/evaluation procedures along with scores of all test administered.
 Relevant background information (i.e., history of disability).
I certify that the above referenced client/patient has a “physical or mental impairment
the substantially limits one or more major life activities of such individual” as defined
by the Americans with Disabilities Act.
In addition, I have the necessary professional qualifications to document my
client/patient’s disability, and the information provided on this form is accurate to the
best of my knowledge.
Name of Professional (please print):
______________________________________________________________
Signature of Professional:
______________________________________________________________
License/certification #: ___________________ Date: ____________________
Address: _______________________________________________________
_______________________________________________________________
Phone #: ______________________________ Fax #:_____________________
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Return this form to as soon as possible so this student may receive accommodations.
Please include the necessary verifying documents from your files.
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