PSYCHIATRIC DISORDER DOCUMENTATION GUIDELINES

A psychiatric disorder assessment must be conducted by a trained, qualified, and licensed professional who has had direct experience in identifying and diagnosing psychiatric disorders in adolescents and adults. The name, title, and professional credentials of the evaluator, including information about license or certification, as well as area of specialization, employment, and state or province in which the individual practices should be clearly stated in the documentation. Clinical psychologists, neuropsychologists, psychiatrists, and other qualified medical doctors are considered qualified to evaluate and diagnose psychiatric disorders. In order to ensure an objective assessment, the professional completing the evaluation should not be a family member. The diagnostic evaluation should be relevant to the student’s learning environment, show the student’s current level of functioning, and show the impact of the condition on academic performance. All reports should be on letterhead, typed, dated, signed, and otherwise legible. The assessment must be current, typically meaning that it was conducted within the last six months. The diagnostic report must include the following:

1.    DiagnosTIC interview

The diagnostic interview should include, but is not necessarily limited to the following:

·        History of presenting symptoms

·        Duration and severity of the disorder

·        Relevant developmental, historical, and familial data

·        Procedures used to diagnose the disorder (include a list of all instruments used in the assessment and test scores as applicable)

·        A description of current functional limitations in the academic environment as well as across other settings

·        Relevant information regarding medications, the student’s history of compliance with medication, and the anticipated impact on the student in an academic environment

·        The diagnostic assessment should examine the possibility of co-existing conditions including medical disorders and learning disorders. The evaluator should consider and discuss the possibility of alternative conditions that may mimic psychiatric disorders.

·        Relevant information regarding current treatment

2.    specific diagnosis

The report must be comprehensive and include a specific diagnosis of a psychiatric disorder based upon the DSM-IV diagnostic criteria. The diagnostician should use direct language, and avoid the use of such terms as “suggests,” “is indicative of,” or “appears.”

3.    Recommended list of academic accommodations