HSC LEARNING SERVICES MEDICAL DOCUMENTATION FORM
Dear Health Care Practitioner,
You are being asked by a student who wishes to access learning accommodations at Hillfield Strathallan College to complete the following documentation.
The following is to be completed by a treating specialist. All sections of the form must be completed carefully and objectively to ensure an accurate assessment of the student’s disability related to needs.
1. Name of patient/student:
2. Date of birth of patient/student: ____________________________________
3. Diagnosis/condition (as per the DSM-5) for learning or physical accommodation:
4. Time under your care: ______________________________________________
5. The anticipated duration of this condition is _________________ to __________________
6. Please indicate the impact of current symptoms on the following major life activities which may affect the student’s education and academic functioning:
LIFE ACTIVITY
Attention and Concentration
Memory (short and long term)
Organization
Stress Management
Rational thinking and reasoning
Social Interactions (i.e., in-class participation)
Managing Internal Distractions
Timely completion of tasks and attendance
Cognitive processing of information
Limited functioning at certain times of day (please specify):
Other (please specify):
Based on the current symptoms you identified, please provide recommendations for specific academic accommodations that may be appropriate for this student:
CERTIFICATE OF ATTENDING PROFESSIONAL:
Signature: _______________________________________________________ Date: _______________________________
Name and Title: _________________________________________________ Registration Number: _________________________________
Address: ________________________________________________________ Official Stamp: Telephone Number: ______________________________________________
Email Address: ____________________________________________________________________________________________________________
STUDENT/PARENT INFORMED RELEASE:
I give consent for Learning Services to contact my medical practitioner or registered psychologist to discuss the information provided in this document if necessary in order to clarify the information regarding providing accommodations:
Signature: ______________________________________________________
Date: _______________________________