Application For Disability Accommodations Page 3
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3APPLICATION FOR DISABILITY ACCOMMODATIONS
PRACTITIONER’S STATEMENT
(A copy of this form must be completed by each health care practitioner providing services to the patient.)
PART II
Practitioner Name: __________________________________________________________________________________
Last
First
Middle/M.I.
Office Address: _____________________________________________________________________________________
____________________________________________________________________________________________
Office Phone Number: ( ____________ ) _______________________
Patient’s Name: _____________________________________________________________________________________
Patient’s Address: ___________________________________________________________________________________
City, State/Province, ZIP/Postal Code: _________________________________________________________________
Patient’s Social Security Number (US)/Social Insurance
Patient’s Birthdate:
Number (Canada)
Month
Day
Year
1. Diagnosis and description of disabling condition: ___________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Date patient first seen: _________________________
Date patient last seen: _________________________
2. Date of onset: ___________________________________________________________________________________
3. Major life activity(ies) limited by disabling condition (e.g., walking, seeing, breathing, etc.) ______________
________________________________________________________________________________________________
________________________________________________________________________________________________
4. Circumstances under which previous accommodations were granted and dates of occurrences: _________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
5. Accommodation(s) needed in this testing situation: _________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
I hereby certify that the above information is true and is released pursuant to authorization by my patient.
Signature of Health Care Practitioner: _________________________________________
Date: ________________
Professional Status
: ____________________________________________________________
(physician, psychologist, etc.)
License Number (if applicable): _______________________________________________________________________
FOR BOARD USE
Board approval, if applicable: _______________________________________________________________
_______________________________
Name
Title
Date
ASWB Social Work Licensing Examination
Revised 2015
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