Forms

To be completed by a Qualified Licensed Provider: Converse College provides testing and classroom accommodations for students with a verified and substantially limiting disability. A student’s documentation must demonstrate the existence of a condition covered by the Americans with Disabilities Act (ADA: 1990). The ADA defines a disability as a physical or mental impairment that substantially limited one or more major life activities. Documentation of such impairment must be derived from a licensed provider who is not a relative of the student. Students must provide this document to their provider to be completed and and returned to Disability Services.

(.pdf, 159K)

To be completed by a Qualified Licensed Provider: A licensed clinical psychologist, clinical neuropsychologist, psychiatrist, or other appropriately trained medical professional with expertise in the field of adult psychological disorders must conduct a complete psychological assessment. Students must provide this document to their provider to be completed and and returned to Disability Services.

(.docx, 23K)

To be completed by a Qualified License Provider: A learning disabilities assessment, which reflects the current impact of identified impairments on academic performance must be done by a licensed professional who is qualified to administer and interpret intelligence and achievement tests, and a diagnostic report based upon the assessment. This assessment must be done by a trained and certified and/or licensed psychologist, learning disabilities specialist, VR staff psychologist, school psychologist, or educational therapist. Students must provide this document to their provider to be completed and and returned to Disability Services.

(.pdf, 128K)

A full assessment for ADHD must be conducted by a licensed clinical psychologist, clinical neuropsychologist, psychiatrist, Vocational Rehabilitation psychologist or school psychologist with expertise in the differential diagnosis of adult psychological disorders.

(.pdf, 115K)

Documentation is required for review of requests for accommodations related to service and assistance animals and must be completed and submitted to the disability services office.

(.pdf, 190K)