Fillable Form 6135332506: QueensStudentAccessibilityServices DisabilityVerification DisabilityCategory:DEVELOPMENTALDISORDER Psychologist,Psychiatrist,DevelopmentalPediatrician,FamilyPhysician (Queen's Univers

Fill Online, Printable, Fillable, Blank Form 6135332506: QueensStudentAccessibilityServices DisabilityVerification DisabilityCategory:DEVELOPMENTALDISORDER Psychologist,Psychiatrist,DevelopmentalPediatrician,FamilyPhysician (Queen's Univers Form

Use Fill to complete blank online QUEEN'S UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 6135332506: QueensStudentAccessibilityServices DisabilityVerification DisabilityCategory:DEVELOPMENTALDISORDER Psychologist,Psychiatrist,DevelopmentalPediatrician,FamilyPhysician (Queen's University)

On average this form takes 58 minutes to complete

The Form 6135332506: QueensStudentAccessibilityServices DisabilityVerification DisabilityCategory:DEVELOPMENTALDISORDER Psychologist,Psychiatrist,DevelopmentalPediatrician,FamilyPhysician (Queen's Univers form is 7 pages long and contains:

  • 2 signatures
  • 250 check-boxes
  • 109 other fields

Country of origin: CANADA
File type: PDF

Canada forms for Queen's University

BROWSE QUEEN'S UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Queen’sStudentAccessibilityServices
Queen’sUniversity
CôtéSharpWellnessCentre,MitchellHall
69UnionStreet|Kingston,ON|K7L3N6
613‐533‐2506
https://www.queensu.ca/studentwellness/accessibility‐services/
DisabilityVerification
DisabilityCategory:DEVELOPMENTALDISORDER
Thisformshouldbecompletedbyoneofthefollowingappropriatelylicensedandtrainedprofessionals:
Psychologist,Psychiatrist,DevelopmentalPediatrician,FamilyPhysician
Pleaseprintclearlyinblackink
STUDENTINFORMATION:
LastName:_________________________ Preferred/GivenName:__________________________
DateofBirth:________________________ StudentNumber:______________________________
Queen’sNetID:___________________________ Phone:_______________________________________
FIELDWORK/PLACEMENTS:
Willyouberequiredtocompletefieldwork(placements/practicums/co‐op)?
YES NO
TypeofFieldwork:__________________________________________________________________________
DateFieldworkBegins:
DISCLOSUREOFDIAGNOSIS:
Note:YouareNOTrequiredtodiscloseyourmedicaldiagnosisinordertoreceiveaccommodationsandsupports.
However,QSASdoesrequireverificationofthenatureofyourdisabilityand,moreimportantly,informationabouthow
itimpactsyouatuniversity.QSASwillusethisinformationtorecommendappropriateaccommodationsandsupports
foryouatQueen’s.
CONFIDENTIALITY:
InformationprovidedtoQSASinthisform,includinganymedicaldiagnosis(es),iskeptstrictlyconfidential.Itisnot
sharedwithanyoneoutsideofQSAS,includingwithotheruniversitydepartments,withouttheexpressedandwritten
consentand/ordirectionofthestudent.
Doyouconsenttoyourmedicaldiagnosisbeingidentifiedonthisformand
communicatedtoQueen’sStudentAccessibilityServices?
YES
NO
RELEASEOFINFORMATION:
IherebyauthorizemyHealthCareProfessional(HCP),whoiscompletingandsigningthisform,toshareinformation
withQueen’sStudentAccessibilityServicesaboutmydisabilityanditsfunctionalimpacts.
StudentSignature: Date:

PersonalinformationiscollectedundertheauthorityoftheQueen’sUniversityRoyalCharter,1841(asamended)andwillbeusedtoprovidedisability‐
relatedservicesandaccommodationsforstudiesatuniversity.
Student’sInformedReleaseisdoneinaccordancewiththefollowingsectionsoftheFreedomofInformationandProtectionofPrivacyAct:41.(1)(a),
41.(1)(b),and41.(1)(c)allowingfortheuseofpersonalinformationandsections42.(1)(b),42(1)(c),and42(1)(d)allowingforthedisclosureofpersonal
information.
click to sign
signature
click to edit
Queen’sStudentAccessibilityServices
Queen’sUniversity
HCPInitial
Page 2 of 7
HEALTHCAREPROFESSIONAL:
Queen’sUniversityisrelyingon,andappreciates,yourdetailedknowledgeofthisstudent’sdisability,especiallyhowits
limitationsorrestrictionsmayimpactontheirlearningatuniversity.Carefulconsiderationshouldbegiventothe
verificationofdisabilityanddegreeoffunctionallimitationinthesectionsbelow.
VERIFICATIONOFDISABILITY:
Ifthestudentconsentedabovetodisclosetheirmedicaldiagnosis,pleaseprovideacleardiagnostic
statement.IncludeDSM‐5Codediagnosisandlevelofseverity.Note:Indicateanyco‐existingdiagnosesor
concurrentconditions,includingDSM‐5codewhereapplicable.
DURATION:
PERMANENT:Ongoing,willimpactthestudentoverthecourseoftheiracademiccareer,andis
expectedtoremainfortheirnaturallife
PERMANENT,EPISODIC:Periodsofgoodhealthinterruptedbyperiodsofillnessordisability,andis
expectedtoremainfortheirnaturallife
TEMPORARY: AnticipatedDuration ______/______(MM,YR)to ______/______(MM,YR)
PROVISIONAL:
Iamstillmonitoring/assessingthestudent.
Assessmentlikelytobecompletedby:______/______/______(DD,MM,YR)
NextClinicalAssessmentDate(ifapplicable):______/______/______(DD,MM,YR)
Ifdurationisunknown,pleaseindicateareasonabledurationforwhichthestudentshouldbe
accommodated:_____________________(numberofmonths)orwhichTERM(S):
FALL WINTER SPRING/SUMMER
PleaseNote:InterimAcademicAccommodationsmaybeprovidedduringtheassessmentperiod.Toextend
theseaccommodations,updateddocumentationmayberequiredforconditionsstillbeingassessed.
ASSESSMENTINFORMATION:
Howlonghasthestudentbeenyourpatient?
Seenforfirsttimetoday 1weekorless 6monthsorless
1yearorless Morethan1year
Willyoubemonitoring/treatingthisstudentwhiletheyareatQueen’s?
YES NO
CLINICALASSESSMENTMETHODSUSED.CHECKALLTHATAPPLY:
ClinicalAssessment Date(s):_____________________________________________________
GlobalAssessmentofFunctioning(GAF)orWHO‐DAS
Score: _________________________
PsychiatricEvaluation Date(s):_____________________________________________________
Neuropsychologicalorpsycho‐educationalassessment Date:__________________________
Pleaseprovideacopy,includingalistoftestscompletedandscores.
BehavioralObservations
Queen’sStudentAccessibilityServices
Queen’sUniversity
HCPInitial
Page 3 of 7
DISABILITYINFORMATION:
Pleaseindicatelevelofseverity: Mild
Moderate Severe
DateofOnset:______/______/______(DD,MM,YR)
Dateofmostrecentassessment:______/______/______ NextAssessment:______/______/______
Hasthestudentbeenhospitalizedfortreatmentofthisdiagnosis? YES
NO
Ifyes,pleaseindicatedateofmostrecenthospitalization:______/______/______
Doesthestudenthaveahistoryofself‐injuryorinjurytoothers?
YES
NO
Doesthestudenthaveahistoryofseizures?
YES
NO
Ifyes,hasasafetyplanbeenestablished?
YES
NO
CURRENTTREATMENT‐Optional:(CheckallthatApply)
Psychotherapy BehavioralTherapy
Grouptherapy OccupationalTherapy
Complementarytherapies(e.g.,yoga,meditation) Physiotherapy
SkillsTraining(e.g.,Social,Self‐Regulation,etc.) Other:
Isthestudentcurrentlytakingmedicationfortheirsymptoms?
YES
NO
Ifyes,pleasespecifyanysideeffectsthatimpactonthestudent’sfunctioning?
v
Queen’sStudentAccessibilityServices
Queen’sUniversity
HCPInitial
Page 4 of 7
RESTRICTIONSANDLIMITATIONS:
Inthefollowingsection,pleaseindicateseverityofdisabilitybasedonthenumberandseverityof
symptoms/restrictions,andtheirimpactonthestudent’sfunctioninginauniversityacademicenvironment.
Pleaseusethefollowingscale:
Note:TheHealthCareProvidermustcompletethissectioninconsultationwiththestudent.Students
shouldnocompletethissectionindependentlywithoutinputfromtheirHealthCareProvider.
Mild:
Noimpact,ormildimpact.Thestudentdoesnotrequireacademicaccommodation.
Moderate: Symptomsareprominent.Thestudentwillrequiresomeacademicaccommodation.
Serious:
Thestudenthasahighdegreeofimpairment.Symptoms/restrictionsmarkedlyinterfereswithacademic
functioning.Studentwillrequiresignificantacademicaccommodation.
Severe:
Symptoms/restrictionssoseverethatstudentisunabletofunctionatanylevelinauniversityacademic
environment,evenwithsignificantacademicaccommodation.
Symptoms/Restrictions Mild Moderate Serious Severe Comment
PHYSICAL:
Repetitiveand
StereotypicalBehavior

PoorCoordination/
ClumsyMovements

Headache

SensitivitytoTactileor
OlfactoryStimuli

SensitivitytoVisual
Stimuli

SensitivitytoAuditory
Stimuli

SLEEP:
Insomnia

PoorSleepHygiene

TroubleFallingAsleep

SleepApnea

THINKING:
DifficultyProcessing
AuditoryInformation

DifficultyProcessing
VisualInformation



Queen’sStudentAccessibilityServices
Queen’sUniversity
HCPInitial
Page 5 of 7

Symptoms/Restrictions
Mild Moderate Serious Severe Comment
DifficultyProcessing
InformationQuickly

DifficultyConcentrating

DifficultyRemembering

Difficulty
Organizing/Planning

DifficultyReasoning&
ThinkingRationally

DifficultyManagingTime
(incl.freetime)

S
OCIO‐EMOTIONAL:
DifficultyRespondingto
Non‐VerbalSocialCues

DifficultyRespondingto
CommonSocialCues

DifficultyUnderstanding
PersonalSpace

DifficultySelf‐Regulating
inDailyActivities

DifficultyInteractingwith
Others

DifficultyExpressing
Empathy

Irritability

Nervousness

LowMotivation

DifficultyMaking
Decisions

DifficultyManaging
RegularStress

DifficultyManaging
InternalDistractions

DifficultyManaging
ExternalDistractions



Queen’sStudentAccessibilityServices
Queen’sUniversity
HCPInitial
Page 6 of 7
COMMUNICATION:
Symptoms/Restrictions
Moderate Serious Severe Comment
DifficultyUnderstanding
Language& Emphasis
ToneVariation
DifficultyUnderstanding
Humor,Metaphors,
Sarcasm
RepetitiveQuestionsor
Comments
SpeechMonotonous,
Rigid,orUnusuallyFast
ACTIVITIES‐Optional:(CheckallthatApply)
Usingthesamescaleabove,pleaseindicatethelevelofimpactofthestudent’sdisabilityandtheirassociated
symptoms/restrictionsonthefollowingactivitiesexpectedoftheminauniversityenvironment:
Activity
Mil
d
Moderate
S
erious
S
evere Comment
AttendingClass
TakingNotes
Reading
Writing
CompletingExams
DeliveringPresentations
MeetingAssignmentDeadlines
ParticipatinginGroupActivities
AdaptingtoScheduleChanges
ParticipatinginLabActivities
AppropriateClassroom
ParticipationandBehavior
Other
Other
Mild
Queen’sStudentAccessibilityServices
Queen’sUniversity
HCPInitial
Page 7 of 7
COURSELOAD:
Isthestudent’sconditionsufficientlystableatthistimetosustainparticipationin
regularuniversityacademicactivities?
YES NO
Inyouropinion,isthisstudentabletomeetthedemandsofafullcourseload(15‐
20hoursofclass,lab,ortutorialmeetingsperweek,plus25‐30hoursofstudytime
perweek?
YES NO
Ifno,pleaseestimatethemaximumamountoftimeinhoursperweekthatthestudentshouldbeableto
spendintheseactivities:_____________________________
AdditionalInformation(Pleaseusethisspacetoprovideanyotherinformationaboutthestudent’sdisabilityandtheir
functionallimitationsthatQueen’sshouldconsiderinsupportingthestudent)
HEALTHCAREPROFESSIONALINFORMATION:
Name:
(PleasePRINT)
FacilityNameandAddress(PleaseuseOfficialStamp)
(Note:Ifyoudonothaveanofficestamp,pleasesign,date,andattachapageofyourOfficeLetterhead)
Specialty:
PsychiatristNeuropsychologist
FamilyPhysician Psychologist
DevelopmentalPediatrician
Other
HealthCareProfessionalSignature: Registration/LicenseNo.:
Date: Phone:
Fax:
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 6135332506: QueensStudentAccessibilityServices DisabilityVerification DisabilityCategory:DEVELOPMENTALDISORDER Psychologist,Psychiatrist,DevelopmentalPediatrician,FamilyPhysician (Queen's University)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 20 October 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document