Accommodation Request Form

Indiana Health Group Accommodation Request Form

Patient Information

Dear Patient,

In order to facilitate your requested application for academic accommodations, we need you to provide detailed information by completing the form below.

Please Note: This form will be attached to your paperwork as part of the documentation required to facilitate your application for academic accommodations.

Online form completed

Patient Name*

First Name

Middle Name

Last Name

Date of Birth

Gender

Male Female

Other:

Current Age

Home Address

Address Line 1

Address Line 2

City

State

ZIP Code

Home Phone Number

Mobile Number

Email Address (optional)

Do you wish for us to use this email address to communicate with you?

Yes No

while convenient, the use of regular email may not be secure

My primary IHG clinician is

School/Institution Name and Address

Address Line 1

Address Line 2

City

State

ZIP Code

Contact person at the school/institution

First Name

Last Name

School/Institution email

School/Institution phone

School/Institution fax

Description of the need for the academic accommodation:

Please explain the reason that you are seeking academic accommodations:

Please indicate what type of accommodations you are requesting:

Additional time on tests Additional time on papers/projects Note taking service/assistance The ability to take tests in an alternate testing location with less noise/fewer distractions Accommodations relating to student housing

Other:

For each to the accommodations requested above, please provide DETAILED and SPECIFIC information explaining why each of the accommodations is needed.

Please indicate your perception of your ability to do the following:

Please indicate your perception of your ability to do the following:
	No impairment	Mild impairment	Moderate impairment	Severe impairment
Attending to personal hygiene/grooming	Please indicate your perception of your ability to do the following:: Attending to personal hygiene/grooming (No impairment)	Attending to personal hygiene/grooming (Mild impairment)	Attending to personal hygiene/grooming (Moderate impairment)	Attending to personal hygiene/grooming (Severe impairment)
Being around others without suffering emotional breakdowns	Being around others without suffering emotional breakdowns (No impairment)	Being around others without suffering emotional breakdowns (Mild impairment)	Being around others without suffering emotional breakdowns (Moderate impairment)	Being around others without suffering emotional breakdowns (Severe impairment)
Cleaning my home	Cleaning my home (No impairment)	Cleaning my home (Mild impairment)	Cleaning my home (Moderate impairment)	Cleaning my home (Severe impairment)
Communicating with others effectively	Communicating with others effectively (No impairment)	Communicating with others effectively (Mild impairment)	Communicating with others effectively (Moderate impairment)	Communicating with others effectively (Severe impairment)
Dealing with other people	Dealing with other people (No impairment)	Dealing with other people (Mild impairment)	Dealing with other people (Moderate impairment)	Dealing with other people (Severe impairment)
Directing/controlling/planning work activities	Directing/controlling/planning work activities (No impairment)	Directing/controlling/planning work activities (Mild impairment)	Directing/controlling/planning work activities (Moderate impairment)	Directing/controlling/planning work activities (Severe impairment)
Driving	Driving (No impairment)	Driving (Mild impairment)	Driving (Moderate impairment)	Driving (Severe impairment)
Exercising good judgement	Exercising good judgement (No impairment)	Exercising good judgement (Mild impairment)	Exercising good judgement (Moderate impairment)	Exercising good judgement (Severe impairment)
Expressing personal feelings	Expressing personal feelings (No impairment)	Expressing personal feelings (Mild impairment)	Expressing personal feelings (Moderate impairment)	Expressing personal feelings (Severe impairment)
Focusing on tasks	Focusing on tasks (No impairment)	Focusing on tasks (Mild impairment)	Focusing on tasks (Moderate impairment)	Focusing on tasks (Severe impairment)
Following specific instructions	Following specific instructions (No impairment)	Following specific instructions (Mild impairment)	Following specific instructions (Moderate impairment)	Following specific instructions (Severe impairment)
Influencing people regarding their opinions, attitudes, etc.	Influencing people regarding their opinions, attitudes, etc. (No impairment)	Influencing people regarding their opinions, attitudes, etc. (Mild impairment)	Influencing people regarding their opinions, attitudes, etc. (Moderate impairment)	Influencing people regarding their opinions, attitudes, etc. (Severe impairment)
Laundry	Laundry (No impairment)	Laundry (Mild impairment)	Laundry (Moderate impairment)	Laundry (Severe impairment)
Maintaining the necessary pace at work	Maintaining the necessary pace at work (No impairment)	Maintaining the necessary pace at work (Mild impairment)	Maintaining the necessary pace at work (Moderate impairment)	Maintaining the necessary pace at work (Severe impairment)
Making good decisions	Making good decisions (No impairment)	Making good decisions (Mild impairment)	Making good decisions (Moderate impairment)	Making good decisions (Severe impairment)
Performing repetitive work	Performing repetitive work (No impairment)	Performing repetitive work (Mild impairment)	Performing repetitive work (Moderate impairment)	Performing repetitive work (Severe impairment)
Performing under stress	Performing under stress (No impairment)	Performing under stress (Mild impairment)	Performing under stress (Moderate impairment)	Performing under stress (Severe impairment)
Physically carrying out my work	Physically carrying out my work (No impairment)	Physically carrying out my work (Mild impairment)	Physically carrying out my work (Moderate impairment)	Physically carrying out my work (Severe impairment)
Planning/arranging/organizing	Planning/arranging/organizing (No impairment)	Planning/arranging/organizing (Mild impairment)	Planning/arranging/organizing (Moderate impairment)	Planning/arranging/organizing (Severe impairment)
Preparing meals/cooking	Preparing meals/cooking (No impairment)	Preparing meals/cooking (Mild impairment)	Preparing meals/cooking (Moderate impairment)	Preparing meals/cooking (Severe impairment)
Shopping	Shopping (No impairment)	Shopping (Mild impairment)	Shopping (Moderate impairment)	Shopping (Severe impairment)
Working alone or in isolation	Working alone or in isolation (No impairment)	Working alone or in isolation (Mild impairment)	Working alone or in isolation (Moderate impairment)	Working alone or in isolation (Severe impairment)
Working without endangering myself	Working without endangering myself (No impairment)	Working without endangering myself (Mild impairment)	Working without endangering myself (Moderate impairment)	Working without endangering myself (Severe impairment)
Working without endangering others	Working without endangering others (No impairment)	Working without endangering others (Mild impairment)	Working without endangering others (Moderate impairment)	Working without endangering others (Severe impairment)

SYMPTOM CHECKLIST

PHQ-9 DEPRESSION RATING SCALE:

Over the last 2 weeks (14 days), how often have you been bothered by any of the following problems?

Over the last 2 weeks (14 days), how often have you been bothered by any of the following problems?
	0 - Not at all	1 - Several days	2 - More than half of the days	3 - Nearly every day
Little interest or pleasure in doing things	Over the last 2 weeks (14 days), how often have you been bothered by any of the following problems?: Little interest or pleasure in doing things (0 - Not at all)	Little interest or pleasure in doing things (1 - Several days)	Little interest or pleasure in doing things (2 - More than half of the days)	Little interest or pleasure in doing things (3 - Nearly every day)
Feeling down, depressed, or hopeless	Feeling down, depressed, or hopeless (0 - Not at all)	Feeling down, depressed, or hopeless (1 - Several days)	Feeling down, depressed, or hopeless (2 - More than half of the days)	Feeling down, depressed, or hopeless (3 - Nearly every day)
Trouble falling asleep or staying asleep, or sleeping too much	Trouble falling asleep or staying asleep, or sleeping too much (0 - Not at all)	Trouble falling asleep or staying asleep, or sleeping too much (1 - Several days)	Trouble falling asleep or staying asleep, or sleeping too much (2 - More than half of the days)	Trouble falling asleep or staying asleep, or sleeping too much (3 - Nearly every day)
Feeling tired or having little energy	Feeling tired or having little energy (0 - Not at all)	Feeling tired or having little energy (1 - Several days)	Feeling tired or having little energy (2 - More than half of the days)	Feeling tired or having little energy (3 - Nearly every day)
Poor appetite or overeating	Poor appetite or overeating (0 - Not at all)	Poor appetite or overeating (1 - Several days)	Poor appetite or overeating (2 - More than half of the days)	Poor appetite or overeating (3 - Nearly every day)
Feeling bad about yourself or that you are a failure or have let yourself or your family down	Feeling bad about yourself or that you are a failure or have let yourself or your family down (0 - Not at all)	Feeling bad about yourself or that you are a failure or have let yourself or your family down (1 - Several days)	Feeling bad about yourself or that you are a failure or have let yourself or your family down (2 - More than half of the days)	Feeling bad about yourself or that you are a failure or have let yourself or your family down (3 - Nearly every day)
Trouble concentrating on things such as reading the newspaper or watching television	Trouble concentrating on things such as reading the newspaper or watching television (0 - Not at all)	Trouble concentrating on things such as reading the newspaper or watching television (1 - Several days)	Trouble concentrating on things such as reading the newspaper or watching television (2 - More than half of the days)	Trouble concentrating on things such as reading the newspaper or watching television (3 - Nearly every day)
Moving or speaking so slowly that other people have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual.	Moving or speaking so slowly that other people have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual. (0 - Not at all)	Moving or speaking so slowly that other people have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual. (1 - Several days)	Moving or speaking so slowly that other people have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual. (2 - More than half of the days)	Moving or speaking so slowly that other people have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual. (3 - Nearly every day)
Thoughts that you would be better off dead, or of hurting yourself in some way.	Thoughts that you would be better off dead, or of hurting yourself in some way. (0 - Not at all)	Thoughts that you would be better off dead, or of hurting yourself in some way. (1 - Several days)	Thoughts that you would be better off dead, or of hurting yourself in some way. (2 - More than half of the days)	Thoughts that you would be better off dead, or of hurting yourself in some way. (3 - Nearly every day)

GAD-7 ANXIETY RATING SCALE:

Over the last 2 weeks (14 days), how often have you been bothered by any of the following problems?

Over the last 2 weeks (14 days), how often have you been bothered by any of the following problems?
	0 - Not at all	1 - Several days	2 - More than half of the days	3 - Nearly every day
1. Feeling nervous, anxious, or on edge.	Over the last 2 weeks (14 days), how often have you been bothered by any of the following problems?: 1. Feeling nervous, anxious, or on edge. (0 - Not at all)	1. Feeling nervous, anxious, or on edge. (1 - Several days)	1. Feeling nervous, anxious, or on edge. (2 - More than half of the days)	1. Feeling nervous, anxious, or on edge. (3 - Nearly every day)
2. Not being able to stop or control worrying	2. Not being able to stop or control worrying (0 - Not at all)	2. Not being able to stop or control worrying (1 - Several days)	2. Not being able to stop or control worrying (2 - More than half of the days)	2. Not being able to stop or control worrying (3 - Nearly every day)
3. Worrying too much about different things	3. Worrying too much about different things (0 - Not at all)	3. Worrying too much about different things (1 - Several days)	3. Worrying too much about different things (2 - More than half of the days)	3. Worrying too much about different things (3 - Nearly every day)
4. Trouble relaxing	4. Trouble relaxing (0 - Not at all)	4. Trouble relaxing (1 - Several days)	4. Trouble relaxing (2 - More than half of the days)	4. Trouble relaxing (3 - Nearly every day)
5. Being so restless that it's hard to sit still	5. Being so restless that it's hard to sit still (0 - Not at all)	5. Being so restless that it's hard to sit still (1 - Several days)	5. Being so restless that it's hard to sit still (2 - More than half of the days)	5. Being so restless that it's hard to sit still (3 - Nearly every day)
6. Becoming easily annoyed or irritable	6. Becoming easily annoyed or irritable (0 - Not at all)	6. Becoming easily annoyed or irritable (1 - Several days)	6. Becoming easily annoyed or irritable (2 - More than half of the days)	6. Becoming easily annoyed or irritable (3 - Nearly every day)
7. Feeling afraid as if something awful might happen	7. Feeling afraid as if something awful might happen (0 - Not at all)	7. Feeling afraid as if something awful might happen (1 - Several days)	7. Feeling afraid as if something awful might happen (2 - More than half of the days)	7. Feeling afraid as if something awful might happen (3 - Nearly every day)

EPWORTH SLEEPINESS SCALE:

Please indicate how likely it would be for your to nod off or fall asleep during the following activities:

Please indicate how likely it would be for your to nod off or fall asleep during the following activities:
	0 - Would never fall asleep	1- Slight chance of falling asleep	2 - Moderate chance of falling asleep	3 - High chance of falling asleep
Sitting and reading	Please indicate how likely it would be for your to nod off or fall asleep during the following activities:: Sitting and reading (0 - Would never fall asleep)	Sitting and reading (1- Slight chance of falling asleep)	Sitting and reading (2 - Moderate chance of falling asleep)	Sitting and reading (3 - High chance of falling asleep)
Watching television	Watching television (0 - Would never fall asleep)	Watching television (1- Slight chance of falling asleep)	Watching television (2 - Moderate chance of falling asleep)	Watching television (3 - High chance of falling asleep)
Sitting inactive in a public place for example a theater or in a meeting	Sitting inactive in a public place for example a theater or in a meeting (0 - Would never fall asleep)	Sitting inactive in a public place for example a theater or in a meeting (1- Slight chance of falling asleep)	Sitting inactive in a public place for example a theater or in a meeting (2 - Moderate chance of falling asleep)	Sitting inactive in a public place for example a theater or in a meeting (3 - High chance of falling asleep)
As a passenger riding in a car for an hour	As a passenger riding in a car for an hour (0 - Would never fall asleep)	As a passenger riding in a car for an hour (1- Slight chance of falling asleep)	As a passenger riding in a car for an hour (2 - Moderate chance of falling asleep)	As a passenger riding in a car for an hour (3 - High chance of falling asleep)
Lying down to rest in the afternoon	Lying down to rest in the afternoon (0 - Would never fall asleep)	Lying down to rest in the afternoon (1- Slight chance of falling asleep)	Lying down to rest in the afternoon (2 - Moderate chance of falling asleep)	Lying down to rest in the afternoon (3 - High chance of falling asleep)
Sitting and talking to someone	Sitting and talking to someone (0 - Would never fall asleep)	Sitting and talking to someone (1- Slight chance of falling asleep)	Sitting and talking to someone (2 - Moderate chance of falling asleep)	Sitting and talking to someone (3 - High chance of falling asleep)
Sitting quietly after lunch (without alcohol)	Sitting quietly after lunch (without alcohol) (0 - Would never fall asleep)	Sitting quietly after lunch (without alcohol) (1- Slight chance of falling asleep)	Sitting quietly after lunch (without alcohol) (2 - Moderate chance of falling asleep)	Sitting quietly after lunch (without alcohol) (3 - High chance of falling asleep)
Driving in a car, while stopped in trafficAll	Driving in a car, while stopped in trafficAll (0 - Would never fall asleep)	Driving in a car, while stopped in trafficAll (1- Slight chance of falling asleep)	Driving in a car, while stopped in trafficAll (2 - Moderate chance of falling asleep)	Driving in a car, while stopped in trafficAll (3 - High chance of falling asleep)

CURRENT MEDICATIONS

Please list each medication, vitamin, supplement you are currently taking including the name, strength, number, and how often you take it during the day

please list one medication per line

FILE UPLOAD (optional)

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Thank you for completing the patient history questionnaire. Please be sure to click the "Submit Form" button below in order to save and send your form securely to our office. If you have any questions, please do not hesitate to contact us at 317-843-9922.