Disability Services Registration Information for Students Counselling and Disability Services 4700 KEELE ST TORONTO ON CANADA M3J 1P3 T 416 736 5297 F 416 736 5633 www.yorku.ca/cds Dear Student, Mental Health Disability Services (MHDS) is one of the disability services within Counselling & Disability Services (CDS). We are an educational service offering academic supports to York University students with a variety of documented mental health disabilities. Please note we do not provide medical treatment or personal counselling and, thus, do not replace mental health supports available in the community. If you wish to register with MHDS, the following is required: 1. Have your medical doctor or registered psychologist (whoever is your primary mental health care provider) complete the enclosed medical documentation form. This request is in accordance with York University s Senate Policy. 2. Complete the enclosed student intake questionnaire. Once we receive this information, you will be contacted to schedule an initial meeting with a disability counsellor. Please set aside approximately one and a half hours so that you are not rushed between classes and arrive 15 minutes in advance to begin the intake process. For more information please visit our web site at www.yorku.ca/cds/mhds. If you have any urgent questions that are not answered on our web site, please do not hesitate to contact our receptionist (416-736-5297), who will direct you to the appropriate person. Please note: Students enrolled at Glendon College should contact the Counselling & Disability Services, Glendon site at 416-487-6709 for disabilityrelated educational support. Mark Mingail, MSW, RSW Manager, Mental Health Disability Services Counselling & Disability Services N110 Bennett Centre for Student Services
COUNSELLING & DISABILITY SERVICES YORK UNIVERSITY Mental Health Disability Services Student Questionnaire Please print neatly Student Number: Date (dd/mm/yyyy): Student Name: Student Email Address: _ Student Telephone Number (home/cell): Program of Study: Undergraduate Masters Ph.D. Certificate How did you hear about us? Did you complete high school? What year? How did you do academically? What session (fall/winter/summer) and year did you first enroll at York University? Did you come straight from high school to York University? Yes No If not, how many years have lapsed since you were in high school? What did you do during those years? Have you been to any other post secondary schools? If yes, please name them, indicate the year(s) you were there and courses, diplomas or degrees completed at these schools. How did you do academically? Are you currently or have you ever been on academic warning at York University? If yes, when? What do you see as your academic strengths and challenges? What strategies do you use to assist you in coping with these challenges? Page 1 of 2
How many courses are you currently enrolled in? How is your education being funded (e.g. OSAP, scholarship)? Have you used any computer technology or disability assistive software to support you with your studies? If yes, list what technologies you have used What are your educational goals? How do you think your disability has affected your academic performance and educational goals? Do you have a good relationship with a mental health professional? If yes, what makes the relationship a good one? Do you have any other social support systems in place? Since we provide educational support, not long-term counselling or crisis work, what are your expectations of our program? Is there anything else we need to know about you that would help us support you in your studies? Page 2 of 2
Mental Health Disability Services Counselling & Disability Services Medical Documentation Counselling and Disability Services 4700 KEELE ST TORONTO ON CANADA M3J 1P3 T 416 736 5297 F 416 736 5633 www.yorku.ca/cds NOTE: This form must be signed and stamped by a medical doctor or a registered psychologist. To be completed by student (please print): Student s Last Name: Student s First Name: Date of Birth(mm/dd/yyyy): Student Number: Address: Phone (Home/Cell): Email Address: Dear Practitioner, You have been asked by a student who wishes to register with Mental Health Disability Services (MHDS) at York University to complete the enclosed documentation. MHDS is an educational support program only. It is primarily meant for students who live with a chronic, persistent and permanent mental health disability and who are involved in university education. Significant temporary mental health disabilities can also be accommodated through our office. As you know, the post secondary environment involves taking examinations, doing research, completing assignments, and assuming responsibility for one s higher education pursuits. The purpose of the medical/psychological documentation is to enable disability counsellors to recommend reasonable and appropriate academic accommodations for students with DSM diagnoses. It is imperative that this form be filled out comprehensively. We need to fully understand the impact on the learning process of the specific functional limitations of the student s disability. We are accountable under the Ontario Human Rights Code and York s Senate Policy on Accommodating Students with Disabilities. These guidelines help us provide academic accommodations that level the playing field for students with disabilities without creating an unfair advantage or undermining academic integrity. We rely on your detailed knowledge of this student s disability, how it impacts his/her education, and the provision of a clear rationale for your recommendations to help us determine the appropriate academic accommodations. Thank you for helping to reduce barriers for students with disabilities while upholding the academic standards of the university. Page 1 of 4
To be completed by medical practitioner or registered psychologist Name/Address/Phone Number Please use office stamp as well as signature Date Diagnosed: (mm/dd/yyyy) Date of your last clinical contact with student: (mm/dd/yyyy) DSM V Diagnosis: Statement of Disability: Check off appropriate statements for this student in the current academic setting: Temporary disability o Student should only require academic accommodation/support for approximately 1 to 3 academic terms o Degree of impairment is: mild moderate severe Long term disability (the mental health disability is expected to impact the student for the entire duration of his/her postsecondary studies) o Degree of impairment is: mild moderate severe o Disability status must be reassessed every due to the changing nature of the illness. How did you arrive at this diagnosis? Check all relevant items below. Structured or unstructured interviews with student Interviews with other persons (parent, teacher, therapist) Behavioral Observations Psycho educational or Neuropsychological Testing Other (please specify) Page 2 of 4
Type of treatment, duration and frequency: Possible side effects of medication(s) on student s academic performance: The DSM V definition of a mental disorder requires that there be significant distress or disability in social, occupational or other important areas of functioning. Please indicate the potential academic impact of this student s mental health condition on the following areas. An explanation of numbers 1 to 4 is given below. Concentration 1 2 3 4 Processing information 1 2 3 4 Retaining information 1 2 3 4 Assignment deadlines 1 2 3 4 Group participation 1 2 3 4 Exam situations 1 2 3 4 Oral Presentations 1 2 3 4 Working Memory 1 2 3 4 1 = No Impact 2 = Mild Impact (the student should be able to cope with minimal support) 3 = Moderate Impact (the student requires some degree of academic accommodation) 4 = Significant Impact (the student has a high degree of impairment with significant academic accommodations required) If Significant Impact, indicated, please elaborate Student s strengths: Student s challenges: Page 3 of 4
A typical recommendation in our service is a course load reduction. Is the student s condition such that it may require him/her to take fewer than what is considered a fulltime course load? Yes. Please explain: No Academic accommodations are intended to level the playing field while maintaining academic integrity. Based on your knowledge of this student and his/her mental health disability, please list specific disability related academic supports/accommodations that you would recommend to assist the student (e.g., to complete assignments, to write tests/exams). Please provide a rationale for these academic accommodations: **Please ensure that this form is completed in full. Incomplete forms will not be accepted. Date Completed (mm/dd/yyyy): Practitioner s Name (please print): Practitioner s Signature: Medical Practitioner s License Number: Registered Psychologist s Registration Number: Return completed form to N110 Bennett Centre or fax this form to: 416 736 5633, Mental Health Disability Services, York University, Attention Leah Collison. Student Consent I give consent for Disability Services within Counselling and Disability Services to contact my medical practitioner or registered psychologist to discuss the information provided in this document Student s Signature: Date(mm/dd/yyyy): _ **Note to student: If you have other relevant documentation, you may include copies of it with this registration package. These additional documents are not intended to replace the MHDS registration package. Please note additional documentation may be requested Page 4 of 4