Disability Documentation Form

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Washington and Lee University provides accommodations for students with disabilities. The documentation provided must demonstrate a disability and need for accommodations.

The form below has been developed to assist the treating or diagnosing healthcare professional (psychiatrist, psychologist, counselor, therapist, medical doctor, optometrist, audiologist, etc) to provide the specific information needed to evaluate the student’s eligibility for accommodations.

The healthcare professional(s) conducting the assessment and/or making the diagnosis must be qualified to do so. The type of professional specialist involved will differ depending on the nature of the diagnosis. However, all professionals must have comprehensive relevant training and must hold a current license in the state in which they practice.

Relevant definitions:

'Disability' is a physical or mental impairment that substantially limits one or more major life activities. A diagnosis of an impairment, though required, does not in and of itself automatically mean that the individual qualifies for a reasonable accommodation. An impairment only constitutes a disability when it prevents an individual from performing a major life activity that the average person in the general population can perform or when the individual is substantially limited as to the condition, manner or duration he/she can perform a particular major life activity as compared to the average person in the general population.
An impairment that is episodic or in remission can constitute a disability if it substantially limits an individual in a major life activity when it recurs.
A 'reasonable accommodation' is a reasonable modification or adjustment to a class or program or the provision of auxiliary aids/services that allows a qualified student with a disability equal opportunity to participate in university programs and activities.

Please fill out the following form on behalf of your client and attach any relevant test results supporting the diagnosis(es). The information you provide will be kept in the student’s file at Disability Resources, where it will be held securely and confidentially. This form may be released to the student at his/her request.

If you have questions regarding this form, please call or email the Director of Disability Resources at 540-458-4055 or kozakl@wlu.edu. Thank you for your assistance.

Student Information

Student Name

Date of Birth

Date of most recent treatment/contact with student

Diagnostic Information

Diagnosis(es)

Date of diagnosis(es)

Please provide a clear diagnostic statement, including what tools or measure were used to assess the student and complete a diagnosis(es).Please provide a copy of any test results supporting the diagnosis(es) or other information used to reach the diagnosis(es).

What is the current severity of the condition without accommodations?

Mild Moderate Substantial Severe

What is the current functional impact of the impairment(s) without any mitigating treatment, medications, etc? In other words, how does the impairment(s) limit(s) one or more major life activities?For each functional impact described in the answer above, please indicate the severity of the impact (mild, moderate, severe).

What is the expected duration, stability or progression of the impairment(s)? If applicable, information on the cyclical or episodic nature of the condition and any known or suspected environmental triggers is recommended.

List current treatments, medications, or assistive devices with an explanation of their effectiveness in accommodating the functional impact of the impairment(s), any significant side effects that may impact functional abilities, and whether/how any such current treatments, medications, or assistive devices bear on the specific accommodations being requested.

What recommendations do you have regarding accommodations to provide equal access to the student’s educational opportunities at Washington and Lee? Please include an explanation as to why each accommodation is recommended due to specific current functional limitations and support recommendations with specific test results or clinical observations.

Description of current and past accommodations. Discuss the use of any prior accommodations, including information about the impact on the student.

Any additional comments or other information you would like to add that might be helpful to us in working with this student?

Qualified Professional's Name and Title

Address

Daytime Telephone Number

License or Certification

State of License or Certification

Type of License

Date

Please note: documentation statement(s) from clinician parents/relatives will not be accepted.