SAS Provider Verification Form

Purpose
Rhodes College strives to meet the needs of students with documented disabilities in accordance with the Americans with Disabilities Act of 1990, as amended, and Section 504 of the Rehabilitation Act of 1973. Students with a significant documented disability or temporary impairment impacting the academic and residential environments may seek accommodations through the accommodation request process administered by the Office of Student Accessibility Services (SAS).

Part of this interactive process requires current, comprehensive documentation of the student's condition. Information provided on this form will be used to assist SAS in determining eligibility and appropriate accommodations.

Please note:

A reasonable accommodation is a modification or adjustment to a course or program that eliminates or minimizes disability-related barriers and enables a qualified student with a disability to participate.
At the college level, the purpose of an accommodation is to correct or circumvent a functional impairment rather than to ensure a student’s success.
A diagnosis alone does not automatically qualify a student for accommodations. A connection must be established between the requested accommodation and the functional limitations on the student in the college environment.
All accommodation requests are considered on an individual, case-by-case basis. When reviewing a student's requested accommodation or an evaluator's recommendation, SAS may find that the accommodation is not reasonable given the essential requirements of a course or program. When possible, SAS may propose an alternative accommodation that would be appropriate for the student.

Instructions
This form should be completed by a qualified professional who is licensed and properly credentialed to diagnose and treat the stated condition(s). The provider must be an impartial individual who is not a relative or close family friend of the student.

Office of Student Accessibility Services

Rhodes College, 2000 N. Parkway, Memphis, TN 38112

Phone: 901-843-3815, Fax: 901-843-3576

Email: SAS@rhodes.edu

PROVIDER INFORMATION

Healthcare Provider Name

Credentials/Licensure

Office Address

Country

Street

City

Region

Postal Code

Phone Number

Email Address

STUDENT INFORMATION

Student Name

Student Birthdate

This student has: (select one)

A physical or mental impairment that substantially limits one or more major life activities (examples of major life activities are listed later in this form)

A temporary impairment (an injury, severe illness, or condition that substantially limits one or more major life activities)

Unsure or unable to determine at present

List current diagnoses, including the specific DSM-V or ICD codes.

Diagnosis #1

Level of severity for this diagnosis:

Mild

Moderate

Severe

Diagnosis #2

Level of severity for this diagnosis:

Mild

Moderate

Severe

Diagnosis #3

Level of severity for this diagnosis:

Mild

Moderate

Severe

Diagnosis #4

Level of severity for this diagnosis:

Mild

Moderate

Severe

Date of Diagnosis

Date of Last Appointment with You

Treatment Plan

Prognosis

Indicate the approximate frequency of symptoms experienced.

Daily

Monthly

Periodic

Seasonal

Does the student experience episodic flare-ups of the condition(s)?

Yes

If YES:
1. What are known triggers of episodes?

2. What is the duration of episodes?

3. What is the care plan for management and recovery from episodes?

Indicate any MOBILITY LIMITATIONS related to walking, stairs, weightbearing, distances they are able to transport themselves, and assistive mobility devices (e.g., use of knee scooter, crutches, cane, wheelchair, etc.).

ACADEMIC ACCOMMODATION RECOMMENDATIONS

List your recommended accommodation(s) for the college academic/classroom environment. Please state the specific student need (e.g., extended time on exams, testing in a distraction-limited environment, etc.) and how the accommodation would mitigate a functional limitation of the condition. (if none, type "none" or "n/a")

HOUSING ACCOMMODATION RECOMMENDATIONS

List your recommended accommodation(s) for the college residential/housing environment. Please state the specific student need (e.g., wheelchair accessible room, visual fire alarm, first floor room, etc.) and how the accommodation would mitigate a functional limitation of the condition. (if none, type "none" or "n/a")

Please note: Accommodations in the residential environment are granted to students with significant documented disabilities only. Adjustments to a student’s residential space due to health-related symptoms that do not rise to the level of a significant disabling condition (e.g., such as living with a particular roommate, living in a particular location, or the desire for a quiet/undisturbed place to study) are considered housing preferences and are evaluated separately by the Office of Residence Life.

Are you recommending a MEDICAL SINGLE ROOM accommodation?

Yes

If YES:

1. How is the student unable to share space with another person?

2. What are the potential risks associated with isolation?

3. What are possible alternatives if your primary recommendation is not possible?

Are you recommending RELEASE FROM RESIDENCY REQUIREMENT as an accommodation?
(All Rhodes students are required to live on-campus for three years.)

Yes

If YES:
1. How does the student's condition prevent them from living in an on-campus residence hall?

2. What recommended housing accommodations would allow the student to live in an on-campus residence hall?

3. What are possible alternatives if your primary recommendation is not possible?

Are you recommending an EMOTIONAL SUPPORT ANIMAL accommodation?

Yes

Please note: Rhodes College SAS considers a student’s request for an emotional support animal (ESA) in the residence hall when the animal is helpful in alleviating one or more of the identified symptoms or effects of the student’s disability. We will accept documentation from providers in the State of Tennessee, or the student’s home state, who have had an ongoing therapeutic relationship with the student.

If YES:
1. Have you recommended and/or prescribed an ESA as part of treatment, or is there an existing pet that you believe will have a beneficial effect for the student while living on campus?

2. What specific symptoms will be reduced by having an ESA?

3. What evidence, if any, is there that an ESA has helped this student in the past or present?

4. Have you discussed the responsibilities associated with properly caring for an animal while engaged in typical college activities and residing in campus housing? Do you believe those responsibilities may exacerbate the student’s symptoms in any way?

5. What other interventions have previously been tried to alleviate the student's mental health symptoms?

ADDITIONAL INFORMATION

Use the space below to provide any additional information that may assist us in determining reasonable accommodations for the student.

Thank you for providing this information.

By signing below, I am verifying that the diagnoses and supporting information provided is accurate, that I am a qualified professional who is licensed and properly credentialed to diagnose and treat the stated conditions, and that I am not a relative or close family friend of the student.