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  1. Student Name
  2. Social Security Number
  3. Date of Birth
  4. Date of evaluation
  5. DSM diagnosis
  6. Describe pertinent history
  7. Summary of present symptoms
  8. Describe what assessment procedures were used
  9. Is the impairment stabilized? What is the prognosis?
  10. Describe the functional nature of the impairment
  11. Describe current medications and possible side effects
  12. Is the student stabilized on the medication?
  13. Are there crisis episodes associated with the impairment?
  14. Describe the student’s functional limitations in an educational setting.
  15. Do you have any recommendations regarding academic accommodations for this student?
  16. Name, signature, and title of evaluator
  17. Date