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Date: Student Name: _____________________________________________________________ Home Address: _____________________________________________________________ City_____________ State____________ Zip Code____________ Telephone: (________)_____________________ Student signature to release requested information: ______________________________________ The above student has requested that you complete the following information to verify their disability. To ensure the provision of reasonable and appropriate services for students with psychological disabilities, students needing such services are required to provide current and comprehensive documentation of their disability. We ask that you complete the following sections or provide a written report that addresses all the areas listed below. Any information you can provide that offers recommendations for necessary and appropriate auxiliary aids or service, academic adjustment, or other accommodation is appreciated. Date of Diagnosis ____________________ Diagnosis (DSM criteria) ______________________________________________ ___________________________________________________________________ Process used to determine diagnosis. ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Diagnostic Interview Summary ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Level of Severity (circle one) Mild Moderate Severe Measures used to assess the following if applicable. Aptitude ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Achievement ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Information Processing ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Social – Emotional ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Provide a summary of the student’s educational, medical, and family history that may relate to psychological disability. ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ QUALIFIED PROFESSIONAL’S SIGNATURE _____________________________ PRINTED NAME AND TITLE ________________________________________ ADDRESS: __________________________________________________________ DAYTIME TELEPHONE: (____)__________________ Return this form to ТщЖЙДЋУНгГЛ­ГіЦЗ Director, Disability Services 1845 Fairmount ТщЖЙДЋУНгГЛ­ГіЦЗ, KS 67260-0132 ТщЖЙДЋУНгГЛ­ГіЦЗ, ТщЖЙДЋУНгГЛ­ГіЦЗ, Kansas 67260-0132 Voice/TDD (316) 978-3309 Fax (316) 978-3114 79e”• 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