Guidelines for the Documentation of Psychiatric Disabilities
Documentation Requirements
A Qualified Professional Must Conduct the Evaluation
Disability Resources (DR) will accept an assessment administered
by a trained, qualified, and licensed professional, who has had direct experience
with adolescents and adults with psychiatric disorders. A qualified professional
may include but is not limited to a medical doctor, psychologist, or student
clinician who is being supervised by a professional. The evaluator's name, title
and professional credentials and affiliation should be provided. The professional
completing the evaluation should not be a family member. All reports should
be on letterhead, typed, dated, signed, and otherwise legible.
Documentation Must Be Current
Reasonable accommodations are based on the current (i.e. within the last six
months) impact of the disability on academic performance. A diagnostic evaluation
should be relevant to the student's learning environment and show the student's
current level of functioning. If documentation does not address the individual's
current level of functioning, a re-evaluation may be required.
Documentation Must Include a Specific Diagnosis
The report must be comprehensive and include a specific diagnosis based on
the DSM-IV-TR diagnostic criteria. It is recommended that the clinician report
the diagnostic criteria used to support the diagnosis. The diagnostician should
use direct language in the diagnosis, avoiding the use of terms such as "suggests"
"appears" or "is indicative of".
Co-existing Conditions
The diagnostic assessment should examine the possibility of co-existing conditions
including medical disorders and learning disabilities. The evaluator should
consider and discuss the possibility of alternative conditions that may mimic
psychiatric disorders.
Documentation Must Be Comprehensive
Documentation should be based on a comprehensive diagnostic/clinical evaluation
that includes the following:
- History of presenting symptoms
- Duration and severity of the disorder
- Relevant developmental, historical, and familial data
- Procedures used to diagnosis the disorder (include a list of all instruments
used in the assessment and test scores as applicable)
- A description of current functional limitations in the academic environment
as well as across other settings
- Relevant information regarding medications, the student's history of compliance
with medication and the anticipated impact on the student in an academic environment
- Relevant information regarding current treatment
Recommendations for Accommodations
A diagnostic report should include specific recommendations for accommodation(s).
A prior history of an accommodation, without a demonstration of a current need,
does not in and of itself warrant the provision of similar accommodation. Each
accommodation recommended by an evaluator should include a rationale. The evaluation
should support the recommendations with specific test results or clinical observations.
If an accommodation is not clearly identified in the diagnostic report, Disability Resources (DR) will seek clarification and, if necessary,
more information, and will make the final determination as to whether appropriate
and reasonable accommodations are warranted and can be provided. DR reserves
the right to request reassessment when questions regarding previous assessment
or previous service provision arise. Depending on accommodations recommended,
additional psycho-educational, neuropsychological or behavioral assessments
may be necessary.
Definitions
Psychiatric disabilities: Comprise a range of conditions characterized
by emotional, cognitive, and/or behavioral dysfunction. A diagnosis of a disorder
does not, in and of itself, meet the definition of a disability necessitating
reasonable accommodations under the ADA or Section 504 of the Rehabilitation
Act of 1973.
Major life activity: Examples of major life activities include walking,
sitting, standing, seeing, hearing, speaking, breathing, learning, working,
caring for oneself, and other similar activities.
Functional limitation: A substantial impairment in the individual's
ability to function in the condition, manner, or duration of a required major
life activity.
