Documentation Form Of Physical Disability - Student Development (Page 2 of 4) in pdf

Documentation Form Of Physical Disability - Student Development Page 2

Page 2 of 4

Documentation of Mental Health/Psychiatric

Documentation of Sensory,

Disability

Services for Students with Disabilities (SSD)

Physical and Medical Disabilities

Student Development Centre – Western University

Diagnostic Statement

Please provide a clear diagnostic statement or indicate that the student’s difficulties do not meet criteria

for a diagnosis. If more than one condition is present that may affect academic progress, please specify

all relevant conditions.

Diagnosis

________________________________________________________________________________________

Date of the condition’s onset: __________________________________________________________________

Date of last clinical assessment: _______________________________________________________________

How long have you been treating this student? ___________________________________________________

Statement of Permanent Disability

The designation of permanent disability has legal implications and is used in determining a student’s

eligibility for government grants and loans. Please refer to the following definition of permanent disability

when answering the question below it.

Permanent disability is defined as a functional limitation due to a disorder that restricts a person’s ability

to perform daily activities necessary to participate in post-secondary studies and is expected to remain

with the person for the person’s expected life.

In your professional opinion, does the student’s condition meet criteria for a permanent disability as

defined above?

Yes □ No □

Please check the appropriate description(s) as they apply to this student’s condition.

(Check all that apply)

□

Not a disabling condition in the current academic setting

□

Temporary disability: anticipated duration from _____________________ to ____________________

□

Permanent disability with ongoing chronic symptoms

□

Permanent disability with episodic symptoms. Is the student currently experiencing symptoms? _____

□

Updated documentation regarding disability status should be reassessed every __________________

because of the changing nature of the illness

Documentation Form Of Physical Disability - Student Development Page 2