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Mental Health Disability Documentation Guidelines

Mental Health Assessment Form

Please have a mental health professional fully complete the assessment form (pdf) and return to our office.

Additional Information:

Definition of a disability:
The Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act of 1973 protect individuals with disabilities from discrimination and mandate the availability of accommodations to ameliorate the impact of the disability to afford equal access to education. Students registered with Student Disability Services (SDS) must meet the statutory definition of disability under these federal laws. In order to determine whether an individual is entitled to these protections, SDS requires objective evidence (documentation) that verifies that the individual’s condition fits the definition of “disability.”
The ADA defines disability as:

  • a physical or mental impairment that substantially limits one or more of the major life activities of such individual,
  • a record of having such an impairment, or
  • being regarded as having such an impairment.

A condition is considered a disability if it prevents or substantially limits the ability to perform a major life activity or significantly restricts the condition, manner or duration in performing the major life activity as compared to the average person. The analysis of “substantially limits” is a comparative term to the average person in severity, impact and duration. Generally a condition must be substantially limiting for more than several months. A condition is not a disability if it results in mild limitations.

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Disability documentation serves two primary purposes:

  1. To establish right to protection from discrimination.

    Non-discrimination is an assurance that individuals with disabilities will not be excluded or provided lesser access to programs and activities based on assumptions rooted in stereotype or perception of ability that are not based in fact. Non-discrimination also provides freedom from harassment based on perceptions of disability.

    Documentation needed for protection from discrimination based on disability without a request for accommodation can be quite brief. A diagnostic statement from an appropriate professional, a past history of recognition as a person with a disability or even self-identification that indicates how others might regard the individual as having a disability could suffice as the basis for protection from discrimination.
  2. To determine the accommodations to which the individual may be entitled.

    Reasonable accommodations include modifications to policy, procedure or practice and the provision of auxiliary aids and services that are designed to provide equal access to programs and services for qualified individuals with disabilities. Accommodations are reasonable when they do not fundamentally alter the nature of a program or service and do not represent an undue financial or administrative burden.

    Documentation required for the provision of accommodations or services must clearly identify functional limitations caused by the condition, and provide direct and logical connections between the limitations and requested accommodations.

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Disability documentation must include the following elements:

  • Credentials of the evaluator
    Disability documentation must be provided by a licensed or credentialed professional with relevant training and experience. Professionals conducting assessments and rendering diagnosis of psychiatric disorders must have training in differential diagnosis and the full range of psychiatric conditions.  The following professionals would generally be considered qualified to evaluate and diagnose psychiatric disorders provided they have comprehensive training in differential diagnosis and direct experience with an adolescent and/or adult population: licensed clinical psychologists, licensed clinical social workers, psychiatrists, and other relevantly trained medical doctors.  The name, title and professional credentials of the evaluator should be clearly stated in the documentation.  Reports should be on letterhead, typed, dated and signed.  Disability documentation may not be provided by an individual who has a personal relationship with the student.
  • Current statement of diagnosis
    Disability documentation must include a current diagnostic statement (DSM-5 or ICD 10), and should include the current overall level of severity of the condition, along with an assessment of all relevant symptoms.  Accommodations are based on an assessment of the current nature and impact of a disability. Mental health conditions may change over time; therefore, current evaluations are critical for providing reasonable accommodations.  In general, this means that evaluations must have been completed within the last six months prior to accommodation requests.  In addition, depending on the nature of the student’s disability, evaluations may need to be updated on a semester-by-semester, or yearly, basis in order to determine continued eligibility.
  • Comprehensive Evaluation
    • Description of the diagnostic methodology
      The documentation must include a description of the diagnostic criteria for the condition and the evaluation method used to render a diagnosis, including medical examinations, formal testing instruments, structured interviews, and observations. The dates of administration must be included, and all scores given as standard scores and percentiles.
    • Relevant history
      The documentation must include history regarding onset, symptoms, recurrences, hospitalizations, and treatment of the current or related condition(s).
    • Assessment of Functional Limitations
      Provide a comprehensive description of the impact of the condition on the student in an academic environment, at home and in social situations. This description must provide evidence that the student is substantially limited in one or more major life activities. Consider the severity of the impairment and its symptoms, frequency and expected duration of symptoms and impact on everyday activities in determining “substantially limiting.”
    • Treatment/medication and prognosis
      Describe the current impact of medication and/or treatment and the anticipated prognosis. Describe the treatment plan. If relevant, provide information about the cyclical or episodic nature of the condition and/or potential triggers that may intensify symptoms.
  • Accommodation recommendations
    It is helpful for the evaluator to recommend accommodations or services in a post-secondary academic setting that will address the functional impact of the condition or its treatment. Accommodation recommendations should be directly connected to the limitations caused by the condition. If accommoda­tions have been used in the past, include a description of the accommodations and information regarding their efficacy. Accommodations are provided to modify, adjust or eliminate a barrier to a course or program to ensure equitable access.

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