Documentation Guidelines

In order to qualify for services and accommodations on the basis of disability, students must submit clinical documentation directly to Student Disability Services. The following guidelines are intended to assist clinicians in their preparation of reports and to inform clients as consumers of clinical services. Additionally, the following guidelines are not intended to comprehensively address the unique information needed for different types of disabilities.  Further, some accommodation requests (e.g. single residence hall room placement) will require additional substantiation of need. Thus, Student Disability Services reserves the right to require the provision of specific information on a case-by-case basis.

Documentation provided will be used by Student Disability Services to evaluate requests for services and accommodations. The evaluation for receiving services includes a review of the documentation itself and an assessment of whether the accommodation(s) would alter the fundamental goals and standards of a program and/or the course itself.

For individuals who have recently been receiving services from a public school system, the information requested would most likely be contained in the Psycho-Educational Evaluation from your most recent review. IEP’s, 504 Plans, or Transition Plans, are not considered clinical documentation and additional information will be required.

For individuals transferring from another college, disability-related information will not be sent with a transcript request. Disability documentation must be requested separately.  Additionally, the disability information that is requested by Whittier College may or may not be included in a previous evaluation. Student Disability Services may request further documentation from a student if it is not in accordance with the following documentation guidelines.

General Documentation Guidelines
Learning Disability Guidelines
Psychological/Psychiatric Disability Guidelines
Physical Medical Disability Guidelines

General Documentation Guidelines

The documentation must be based upon an evaluation by a healthcare or mental health professional appropriately licensed by the state to diagnose medical, psychological, and learning disorders.  Such persons are usually physicians, psychiatrists, psychologists, and school psychologists.  Documentation from third parties or from persons not licensed to diagnose such conditions will not be accepted.

  1. The documentation must be based upon a clinical evaluation thorough enough to objectively establish the need for accommodations and/or services.
  2. The documentation should be printed on professional letterhead and signed by the evaluator.  Additionally, the license number of the clinician is requested.
  3. The documentation should include the contact information for the clinician.  This information is crucial because Student Disability Services will not release clinical documentation to third parties or to students without first obtaining the permission of the clinician if the documentation was sent directly from the clinician to Student Disability Services. The handling of documentation in this manner is done because harm could occur if untrained persons obtain clinical information and data.
  4. The clinician submitting the documentation must not be a family member or relative of the student.
  5. Documentation will be accepted from student interns and from clinicians under supervision provided the supervisor is qualified and appropriately licensed. The supervisor must co-sign the report and must list his/her license number.
  6. Student Disability Services asks that a copy of the person’s signed release of information form accompany any reports sent directly from clinicians.

Learning Disability Documentation Guidelines

The evaluation to determine whether a person possesses a learning disability must be conducted by an individual who is qualified and appropriately licensed to diagnose learning disabilities.

  1. The evaluation must minimally include the administration of a measure of intellectual ability (e.g. Wechsler Adult Intelligence Scales – 3rd Edition) and a measure of academic achievement (e.g. Wechsler Individualized Achievement Test – 2nd Edition, Woodcock Johnson Tests of Achievement, 3rd Edition).  It is recommended that consideration be given to the presence of other medical or psychological conditions that mimic learning disabilities and/or that impair academic performance.
  2. The diagnosis of a learning disability must be based upon established clinical criteria (e.g. Diagnostic and Statistical Manual of Mental Disorders – 4th Edition).
  3. Test scores should be included in the report.  This would include I.Q. scores, factor scores, and subtest scores. Additionally, indication of the classification ranges associated with the scores should be present (e.g. average, high average, impaired).
  4. Concerns regarding the validity of the evaluation and its findings should be addressed.  This would include factors such as limitations in the test’s norming sample, performance impairments resulting from comorbid medical and psychological conditions, academic difficulties related to acculturation issues, and the client’s motivation for testing.
  5. Recommendations for accommodations should be provided. The test findings should provide a logical rationale for the recommended accommodations.

Psychological/Psychiatric Disability Documentation Guidelines

  1. The documentation must be submitted by a clinician who is qualified to diagnose and treat psychological disorders.  The clinician must be licensed or under the supervision of an appropriately licensed mental health clinician.  Such a clinician is usually a psychologist, licensed marriage and family therapist, licensed social worker, or psychiatrist.
  2. The evaluative methods used to establish the diagnosis should be indicated (e.g. clinical interview, psychological assessment battery).
  3. Test scores from measures of cognitive, neuropsychological, and academic functioning should be provided, if administered.
  4. A diagnosis consistent with established clinical criteria (e.g. DSM-IV) must be given.  Indication of the person’s present symptoms and their degree of impairment (e.g. Global Assessment of Function score) should be provided.
  5. Information regarding how the person’s condition impacts him or her in an academic environment should be provided.  This would include information about academic, personal, and interpersonal functioning.
  6. Recommendations for accommodations should be provided.  The requested accommodations ought to logically flow from the diagnosis and the associated symptoms.
  7. Information about the person’s prognosis for improvement and the timeline for a re-evaluation should be provided.  Because many psychological conditions follow a transient course and often improve with treatment and with time, annual re-evaluations are generally required by the Office of Student Disability Services for persons receiving accommodations on the basis of psychological disability.

Physical / Medical Disability Documentation Guidelines

  1. The documentation should be provided by a clinician qualified and appropriately licensed to diagnose and treat physical and medical disorders.  Such persons are usually physicians and other health specialists.
  2. A diagnosis of a physical or medical condition consistent with established clinical criteria must be given.
  3. The documentation should indicate the functional impact that the physical or medical condition has upon the person in an academic environment (e.g. attendance, stamina, fatigue, mobility, work completion).
  4. Information regarding the nature and course of the physical or medical condition should be provided (e.g. chronic, intermittent, situational).
  5. Recommendations for accommodations should be made that logically flow from the person’s condition and associated difficulties.
  6. Information regarding the need for a re-evaluation should be provided.