Provider Documentation for AD(H)D, Psychiatric, and ...



Provider Documentation for AD(H)D, Psychiatric, and Neurological DisordersGettysburg CollegeI. StudentThis section is to be completed by the student.Last Name: FORMTEXT ?????First Name: FORMTEXT ?????Middle Initial: FORMTEXT ?????Date of Birth: FORMTEXT ?????Phone: FORMTEXT ?????Address: FORMTEXT ?????II. Certifying ProfessionalThis section and subsequent sections are to be completed by the healthcare professional (please note guidelines below for appropriate provider).Full Name: FORMTEXT ?????Area of Specialty: FORMTEXT ?????License or certification number, and state: FORMTEXT ?????Phone: FORMTEXT ?????Email Address: FORMTEXT ?????Address: FORMTEXT ?????Documentation Guidelines: Assessment must be completed by a licensed psychologist, neurologist, neuropsychologist, psychiatrist, or physician known to specialize in psychiatric disorders. Because psychiatric and neurological disorders can change over time, documentation must be up to date. The evaluation should have been completed or updated within the past year. The initial evaluation in which the psychiatric or neurological disorder was diagnosed should be included. The current psychiatric or neurological update can be the completion of the Documentation for Psychiatric and Neurological Disorder Form or a comprehensive report that outlines all the components of the form.Please note: A one-page memo, a one-page letter, or a script that merely outlines diagnoses and recommendations for accommodations is not acceptable. If the student has a learning disability or suspected learning disability, the student should be referred for a psychological or neuropsychological evaluation, if one has not been completed within the past three years.III. Diagnosis1. What were the dates you met with this student? FORMTEXT ?????2. Please attach information to substantiate the diagnosis (or diagnoses). Appropriate information could include, for example, thorough psychiatric or neurological evaluation. If standardized assessment was completed, please attach all scores or results and a brief discussion of each. FORMTEXT ?????3. Please list DSM-5 or ICD-10 diagnostic codes, date(s) diagnosed, and indicate which constitutes the disabling condition. FORMTEXT ?????IV. Statement of Disability1. Disability confirmationIn your opinion, does any condition listed above substantially limit a major life activity and thereby rise to the level of disability? *Yes: FORMCHECKBOX No: FORMCHECKBOX Not Sure: FORMCHECKBOX a. If YES, indicate which ones: FORMTEXT ?????* A disability is defined under the Americans with Disabilities Act as “A physical or mental impairment that substantially limits one or more major life activities.”2. Date of diagnosisWhen was this student first determined to have a disabling condition? FORMTEXT ?????3. Previous accommodationsWhat accommodations for this condition has the student received in the past? FORMTEXT ?????V. Functional LimitationsPlease describe degree of functional limitation for the condition(s)—mild, moderate, severe—and provide an example of how this limits a major life activity. FORMTEXT ?????VI. Recommended Accommodations How to describe requested accommodations:For each recommendation, please indicate if this is essential or preferred. “Essential” means the student cannot participate equally in the educational experience unless this accommodation is in place—nothing else will do. “Preferred” means that an accommodation is desirable but not essential for equal participation.If housing accommodations are being recommended please clearly identify the need. For dietary accommodations, the student must first meet with Dining Services. Only then will our office consider alternate options such as residential kitchen access.A specific diagnosis does not guarantee a specific accommodation: please describe this student’s unique needs.Recommendation: FORMTEXT ????? FORMCHECKBOX Essential FORMCHECKBOX PreferredRecommendation: FORMTEXT ????? FORMCHECKBOX Essential FORMCHECKBOX PreferredRecommendation: FORMTEXT ????? FORMCHECKBOX Essential FORMCHECKBOX PreferredRecommendation: FORMTEXT ????? FORMCHECKBOX Essential FORMCHECKBOX PreferredRecommendation: FORMTEXT ????? FORMCHECKBOX Essential FORMCHECKBOX PreferredRecommendation: FORMTEXT ????? FORMCHECKBOX Essential FORMCHECKBOX PreferredVII. Supplemental Information1. MedicationIs the student taking medication for this condition? FORMTEXT ?????2. SymptomsWhat symptoms remain despite medication treatment? FORMTEXT ?????3. ComplianceWhat is the student’s level of compliance with the treatment regime? FORMTEXT ?????4. TherapyWill the student require therapy at college?Yes FORMCHECKBOX No FORMCHECKBOX 5. PrognosisWhat is the likelihood of the student’s ability to function effectively in a college environment?With recommended treatment regime:Poor FORMCHECKBOX Fair FORMCHECKBOX Good FORMCHECKBOX Excellent FORMCHECKBOX Without recommended treatment regime:Poor FORMCHECKBOX Fair FORMCHECKBOX Good FORMCHECKBOX Excellent FORMCHECKBOX 6. Other comments or recommendations FORMTEXT ?????VIII. Specialist’s SignatureSignature: FORMTEXT ?????Date: FORMTEXT ?????Form SubmissionSubmit completed form to:Office of Academic AdvisingGettysburg College300 North Washington StCampus Box 414Gettysburg, PA 17325Phone: (717) 337-6579Fax: (717) 337-6245Office Use OnlyHealthcare Professional Office stamp:rev. 04Sep19 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download