Documentation Guidelines for Psychological Disabilities

Office of Disability Services | Document Guidelines | Documentation Guidelines for Psychological Disabilities

Comprehensive Documentation Should Include:

Letterhead of diagnostician
Date of last visit.
DSM-IV Diagnosis/date of diagnosis
Assessment procedures used to make the diagnosis
Historical data taken into account in making the diagnosis.
Major symptoms currently being manifested.
Level of symptom severity (Global Assessment of Functioning)
A mental impairment rises to the level of a disability when it substantially limits one or more major life activities of the individual. Please indicate what major life activity is currently impacted and how/to what degree it is limited. Please attach any test results, etc. you used to measure these limitations.
Please discuss any current medications this individual is taking and the impact it has on the limitations described above.
What is the treatment plan and prognosis (expected duration).
Signature of individual with credentials to make the above diagnosis