Student's Name: §) Please attach all relevant assessment data (ine Psychiatric evaluation, and standardized t luding clinieal interview, results of psychological / est scores), Signature: oe Print Name and Title: ee License saeco Ageney Name: ee Street Address; PLEASE MAIL, EMAIL, or FAX COMPLETED FORM TO: Student Accessibility ang Support Services Joseph P. Vona Academic Annex, Room 8 Rider University 2083 Lawrenceville Road Lawrenceville, NJ 08648-3099 Email:_ accessibility @rider.edu Fax: 609-895.5507 Phone: 609-895-5492 Updated ay 2018 “ JAS New Student forms) Pychoiagca DocumentatonStudent's Name: 3) Please identify any treatment in which the student is currently involved. ee eee eee eS eee 4) Please list all currently prescribed medication and any gi ich may i , erate ide effects which may impact the student's 5) What other information do you consider relevant to this student’s ability to succeed in a college setting? {G\Servtdstu\SASS New Student Forms\ Psychological Documentation Form Updated uty 2018Student's Name: 2) Please indicate student's current symptoms, likely impact on academic functioning ina college setting. and recommended academic accommodations: ‘Symptoms: ee ee —— Ccarapdinceseemmsessesseememeessmere esse a — aera pee eee Functional Limitations: i — —— Se SS Ss Recommended Academic Accommodations: ‘serves \SAS New student Forms Psychol Dacumentaten Fm Updates uy2018 =a