Referred to Disability Advisor:

Accessibility Services Confidential Information Form

Date: _______________________ Last Name: ________________________________________________________________

First Name: ________________________________________________________________ Student Number: ________________________________ Age: _________ Sex: ________ Sessional Address: __________________________________________________________ City: ________________________________________ Postal Code: __________________ Email Address: ______________________________@utoronto.ca
(Please note: Important information and notices will be sent to this address. Please check it often for email.)

Telephone: Type: Primary Home Work Cell Pager Alternate Home Work Cell Pager Phone Number: (_______) ____________________ (_______) ____________________ Sessional Permanent Yes No Name & phone # only. Session(s): Sessional Permanent May we leave a message? Yes No Name & phone # only.

Have you used our services before? Yes No If yes, who was your primary contact_____________________________, and when were you here? _____________________________________.

What is your current status at the University of Toronto? Part-Time Student (0.5 to 2.5 courses) Special Student Full-Time Student (3.0 or more courses) Visiting Student Undergraduate students: How many credits have you earned? 0 - 3.5 4.0 - 8.5 9.0 -13.5 14 or more
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Access Programs Academic Bridging Program Transitional Year Program Special Student ________________________ St. George Campus Undergraduate: Arts & Science Innis College New College Saint Michael's College Trinity College University College Victoria University Woodsworth College (See also Professional Faculty) Degree:_________________ Program:________________ ________________________

Professional Faculty Applied Science & Engineering Architecture Dentistry Forestry Law Medicine Music Nursing Occupational Therapy OISE/UT Pharmacy Physical Education & Health Physical Therapy Radiation Science Social Work Toronto School of Theology Degree: ____________________

Graduate Studies: Degree: ______________________ Program: ______________________ ______________________ Stage in program: Course work Comprehensive Thesis ______________________ UTM/UTSC Undergraduate You must first register with Accessibility Services on your home campus. Arts & Science UTM Arts & Science UTSC ______________________ International Student? Yes No

With which areas do you need assistance? Chronic Health Problem (e.g. epilepsy/MS/MD/IBD/Cancer) Mobility/Functional Disability (e.g. CP/Polio/RSI) Mental Health Condition (e.g. Depression/Bipolar/Anxiety Disorder/OCD) Learning Disability or ADHD Head Injury Sensory Disability (e.g. Hearing/Vision)
For Office Use Only: Registration YES NO

Temporary (Please describe): ______________________ Other (Please describe): ______________________

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THE INFORMATION ON THIS FORM IS CONFIDENTIAL. IF YOU NEED ASSISTANCE COMPLETING THIS FORM, PLEASE ASK AT THE FRONT DESK.

ACCESSIBILITY SERVICES Initial Questionnaire for Students with Mental Health Related Issues If you require assistance completing this form or need it in alternative format, please ask at the front desk. Please answer the following questions as completely as possible. The information you provide will help us to develop an accommodation plan that meets your individual needs. 1. What brings you to Accessibility Services at this time? ___________________________________________________________________

2. Who referred you to Accessibility Services? 3. When did you first register at the U of T? _____________________________ 4. Did you recently (within 2 years) complete high school or studies at another educational institution? Yes - please check one - high school No If yes, please list any disability-related accommodations you received. other

5. Please list adaptive technology and equipment you currently use to attend school and complete your academic work: (ie. CCTV, FM System, specialized software)

6. Have you applied for OSAP? If yes, are you OSAP eligible?

Yes Yes

No No

7. Have you ever been on academic probation or suspension? If yes, please provide details.

Yes No

8. What are your reasons for attending the University of Toronto? What are your academic/career/life goals?

9. What is your health disability?

10. Is your disability: (please check one): Permanent Progressive Temporary

11. Please list your current medications and any side effects, if any:

12. Have you ever had a head injury?

Yes No

If yes, please list the year the injury occurred

12.Has anyone ever told you that you may have a learning disability? Yes No 13.What challenges does your disability pose for you at university? For first year students, what challenges did your disability pose for you during high school?

14. How has your disability affected your schoolwork in the past month? Are you up to date in readings and assignments?

15. How many hours a week do you spend: Studying # ____hours Paying job # ____hours

Please feel free to write any additional comments or questions:

RELEASE OF INFORMATION TO BE COMPLETED BY STUDENT

I,__________________________________________, hereby authorize the above named professional to provide the following information to Accessibility Services at the University of Toronto and if required to supply additional information relating to the provision of my academic accommodations and disabilityrelated services. I also authorize Accessibility Services to contact the physician to discuss the provision of accommodations. Students Signature:_________________________________________ University of Toronto Student Number: __________________________ Date:___________________________ Thank you for taking the time to complete this form The information will facilitate the supports requested by your patient while at the University of Toronto

ACCESSIBILITY SERVICES Programs and Services for Students with a Disability CONFIDENTIALITY Confidentiality of information is the foundation of an effective service for students with disabilities. As well as a requirement by law, Accessibility Services believes that this practice generates a students trust and confidence. Accessibility Services staff treat any information we learn about students in interviews, personal communications, and/or reports from other professions as confidential. Only with the students permission do we convey information about his/her disability with U of T staff members outside our service. The level of disclosure is on a need-to-know basis, meaning that not all information provided by a student to the service is shared with an individual faculty member or administrative staff. There are also several legal or ethical limitations to confidentiality: clinicians shall reveal information when there is a suspicion of child abuse, when students pose a significant danger to themselves or others, when students report sexual abuse by a health care professional, or when the court issues a subpoena for records or testimony. Students may wish to disclose to their instructors that they are registered with Accessibility Services. Our staff believes that a three-way partnership with the student, Accessibility Services, and university staff (e.g., faculty, faculty registrars, etc.) paves the way for the best opportunity for a student to be successful at university. We believe that the three parties working together, in concert, promotes understanding and puts the students educational experience on a more level playing field. The University of Toronto Accessibility Services has a diverse staff that has expertise with different disabilities. In order to offer students the most efficient and best possible service, we need you to identify your disability in order to put you directly in contact with the professional who can best help meet your accommodation needs. The information you provide us, through forms, interviews, personal communications, and reports, is held in strict confidence. Please read and sign the following: I understand that any personal information I disclose to staff, including documentation of my disability, will be maintained in confidence within Accessibility Services. I further understand that when Accessibility Services is recommending academic or other accommodations on my behalf, information about the accommodations (not including specific details about the nature of my disability) will be communicated to appropriate University staff at the discretion of Accessibility Services for Students. With the exception of the legal and ethical limits to confidentiality noted above, information about my disability, including documentation, will only be communicated to individuals external to Accessibility Services for students with my permission. I give permission to my Advisor/Counsellor to view my academic records on ROSI. I understand that test/exam accommodations will be shared with the Office of Space Management test/exam office.

Student Signature: ___________________________________ Date:_________________________________

UNIVERSITY OF TORONTO

ACCESSIBILITY SERVICES
Programs and Services for Students With a Disability
130 St. George Street, 1st Floor, Toronto, Ontario M5S 3H1 Tel: 416-978-8060*Fax: 416-978-8246*TTY: 416-978-1902

Documentation for Students with Mental Health Related Disabilities To receive support from Accessibility Services a student must communicate his or her needs in sufficient detail and co-operate in consultations to enable the person responsible for accommodation to respond to the request. (Ontario Human Rights Code Guidelines, 1994, p.17). The OHRC Guidelines (1994) also notes that the university, as the body responsible for accommodating, must have sufficient information to properly assess the impact of the disability on the specific academic task and know how to make the requested accommodation. In order to be accommodated, students who register with Accessibility Services who have health related disabilities must provide sufficient documentation, to verify the disability, and the functional impact of the disability on the students academic performance. This documentation must come from a practitioner who is certified in the areas of the disability(ies), e.g., a psychiatric diagnosis may come from a psychiatrist, registered psychologist, or registered clinical social worker.

Please return completed form to: Accessibility Services, University of Toronto 130 St. George Street, 1st floor, Toronto ON TEL: 416-978-8060 FAX: 416-978-8246

MEDICAL CERTIFICATE for MENTAL HEALTH RELATED ISSUES

This patient is requesting disability-related supports and accommodations while studying at the University of Toronto. The student is required to provide the University with documentation that is: provided by a licensed health-care professional, qualified in the appropriate specialty thorough enough to support the accommodations being considered or requested Note: A diagnosis alone does not automatically mean disability-related accommodation is required The provision of all reasonable accommodations and services is assessed based on the current impact of the disability on academic performance. Generally this means that a diagnostic evaluation has been completed within the last year.

CONFIDENTIALITY Collection, use, and disclosure of this information is subject to all applicable privacy legislation TO BE COMPLETED BY A REGULATED HEALTH PRACTITIONER PLEASE PRINT CLEARLY Patients Name: _______________________________________________________________ Patients University of Toronto Student Number: ______________________________________ Date of Birth:_____/_____/_____ (Year, Month, Day) How long have you been treating this patient ?________________________________________ Last date of Clinical Assessment:___________________________________________________ STATEMENT OF DISABILITY Please indicate the appropriate statement for this student in the current academic setting: Permanent disability with on-going (chronic or episodic) symptoms (that will significantly impact the student over the course of his/her academic career)

Temporary with anticipated duration from ___/___/___ to ___/___/___ (Year, Month, Day) *If unknown, please indicate reasonable duration for which s/he should be accommodated/supported at this time (please specify number of weeks/months):

___________________________________________________________________________

DIAGNOSIS AND CONCURRENT CONDITIONS Please provide a clear diagnostic statement; avoiding such terms as suggests or is indicative of. If the diagnostic criteria are not present, this must be stated in the report. Please note any multiple diagnoses or concurrent conditions. Please note all applicable: Primary Mental Health Disability: (a DSM IV diagnosis) _______________________________________________________________________________________ Secondary Mental Health Disability: (a DSM IV diagnosis) _______________________________________________________________________________________ Additional / Other: ________________________________________________________________________ MEDICATION(S) N/A Brand/Generic Name and dosage: ________________________________________________________________________________________ Brand/Generic Name and dosage: ________________________________________________________________________________________ Brand/Generic Name and dosage: ________________________________________________________________________________________
POTENTIAL SIDE EFFECTS OF MEDICATION(S) ON ACADEMIC PERFORMANCE:

_________________________________________________________________________________________ Current treatment: (counseling, psychotherapy, acupuncture, massage therapy, etc.) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ IMPACTS ON ACADEMIC FUNCTIONING (please specify where possible)

Energy level (please specify impact e.g. fluctuating): ___________________________________________ Impact on Sleeping Cycles: _______________________________________________________________ Ability to manage full work load: ____________________________________________________________ Recommendations for assignments/tests/exams: ______________________________________________

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COGNITIVE IMPACTS: Attention and Concentration Communication Information processing (written and verbal) Memory Organization and time management Social interactions Stress management Other/comments: __________________________________________________________________________________________ Does this individual require any adaptive equipment (lap top, voice recorder), software (Inspiration, Kurzweil) or other supports (massage, light box, counseling etc.) to achieve academic success? Yes No Please be specific about what is required. __________________________________________________________________________________________

HEALTH CARE PRACTITIONER INFORMATION

Name of Health Practitioner (please PRINT): Facility Name and address Note: If you do not have an office stamp please sign and attach your letterhead signatures on prescription pads will NOT be accepted Please use office stamp Specialty: Physician o Family o Psychiatrist Psychologist Other: _______________________________ Health Practitioner Signature: License / Registration No. Date Telephone No. Fax. No

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