The student named below has applied for services from the Disabled Students' Program (DSP) at UC Berkeley. In order to determine eligibility and to provide services, we require documentation of the student's psychological disability.

Under the Americans with Disabilities Act (ADA) of 1990 and Section 504 of the Rehabilitation Act of 1973, individuals with disabilities are protected from discrimination and may be entitled to reasonable accommodations. To establish that an individual is covered under the law, documentation must indicate that a specific disability exists and that the identified disability substantially limits one or more major life activities. A diagnosis of a disorder in and of itself does not automatically qualify an individual for accommodations. The documentation must also support the request for accommodations and academic adjustments.

After completing this form, please print it out, sign it, and mail or FAX it to us at the address in our letterhead. The information you provide will not become part of the student's educational records, but will be kept in the student's file at DSP, where it will be held strictly confidential. This form may be released to the student at their request. In addition to the requested information, please attach any other information you think would be relevant to the student's academic adjustment. Please contact us if you have questions or concerns. Thank you for your assistance.

1. Student's Name:

Today's Date:

Month Day Year

2. What is your DSM-IV multi-axial diagnosis for this student?

Axis I:
Axis II:
Axis III:
Axis IV:

Axis V (GAF score):

3. Date of above diagnosis:

Month

Day

Year

4. Date student was last seen:

Month

Day

Year

5. In addition to DSM-IV criteria, how did you arrive at your diagnosis? Structured or unstructured interviews with the student
Interviews with other persons
Behavioral observations
Developmental history
Educational history
Medical history
Neuro-psychological testing. Date(s) of testing?
Psycho-educational testing. Date(s) of testing?
Standardized or nonstandardized rating scales
Other (Please specify):

6. Please check which of the major life activities listed below are affected because of the psychological diagnosis. Please indicate the level of limitation.

Life Activity	No Impact	Moderate Impact	Severe Impact	Don't Know
Concentrating
Memory
Sleeping
Eating
Social interactions
Self care
Managing internal distractions
Managing external distractions
Timely submission of assignments
Attending class regularly and on time
Making and keeping appointments
Stress management
Organization

7. Is this student currently taking medication(s) for these symptoms?
Describe medication(s), date(s) prescribed, effect on academic functioning, and side effects.
Do limitations/symptoms persist even with medications?

8. What is the student's prognosis? How long do you anticipate the student's academic achievement will be impacted by this disability?

9. Other Information...
What other specific symptoms currently manifesting themselves might affect the student's academic performance?
Is there anything else you think we should know about the student's psychological disability?

10. CERTIFYING PROFESSIONAL*   Fill in this section by hand on the printed form:

Signature of Professional		Date
Professional's Name (printed) and Title		License No.
Address		Telephone No.
City, State, Zip		Fax