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:
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Ageney Name:
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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 DocumentatonStudent's Name:
3) Please identify any treatment in which the student is currently involved.
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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 2018Student's Name:
2) Please indicate student's current symptoms, likely impact on academic functioning ina college setting.
and recommended academic accommodations:
‘Symptoms:
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Functional Limitations:
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Recommended Academic Accommodations:
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