Disability Resource Center Support Services Evaluation Request Form

Disability Resource Center
Support Services Evaluation Request Form

Below you will find a release of information as well as a list of service providers in Broward, Miami-Dade, and Monroe counties. The release will be important since some service providers may require a document from FIU-DRC acknowledging that you are working with our office, in addition to any forms they may need you to complete from their office. Please fill out this form in its entirety and feel free to ask you Access Consultant any questions you may have.

Support Service Evaluation has been recommended for the following student:

Name: __________________________________________ Panther ID: _______________________________
Phone Line: _________________________________ E-Mail: __________________________________

Disability Resource Center staff working with student:

Name: __________________________________________
Phone Line: _________________________________ E-Mail: __________________________________

Comments:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Release of Information:

Student’s Health Service Provider:

Name: _______________________________________________ Phone:__________________________________
Address:______________________________________________________________________________________
Fax:_________________________________ Health Care Provider Contact:________________________________

I, _____________________________ ________hereby give the above mentioned health service provider and Florida International University’s Disability Resource Center permission to exchange information regarding my physical, mental, and/or emotional status. The purpose of this exchange is to benefit my educational pursuits and I may void this release at any time by written or verbal notice to either party mentioned above.

Comments:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Student’s Signature: __________________________________________ Date: __________________

Student’s Printed Name: ______________________________________

Miami-Dade County Locations:

FIU Counseling and Psychological Services (CAPS)

MMC Office: BBC Office:
11200 SW 8^th st UHSC 270 3000 NE 151^st WUC 320

Miami FL 33199 North Miami, FL 33181

Phone: [phone] Phone: [phone]

MMC Office Hours BBC Office Hours
Mon, Wed, Fri / 8AM - 5PM Mon - Fri / 8AM - 5PM & Tues, Thurs / 8AM - 6:30PM
University of Miami Counseling Center GoodMan Center (Carlos Albizu University)

5600 George Merrick Dr Bldg. 21 R 2173 NW 99th Ave

Coral Gables, FL 33146 Doral, FL 33172

Phone: [phone] Phone: [phone]

Hours: MWF 8:30am-5pm Hours: Monday - Thursday: 11:00 am to 9:00 pm

T&TH 830am-7pm Saturday: 9:00 a.m. to 3:00 p.m.
Miami Counseling and Resource Center West Flagler Comprehensive Service Center

111 Majorca Ave 3850 West Flagler St

Coral Gables, FL 33134 Miami, FL 33134

Phone: [phone] Phone: [phone]

Hours: Mon-Fri 8:30am-7:00pm Hours: M-Fri 8:30am-5pm
Broward County Locations:

Nova Southeastern Psychological Services Center Delta Psychological Group

Maltz Building3301 College Avenue 17501 Biscayne Blvd #450
Ft. Lauderdale-Davie, FL 33314 Miami, FL 33137

Phone: (954) (678-2273) Phone: [phone]

Hours: Mon-Fri 8:00am-5:00pm Hours: Mon-Fri 8am-8pm
Chrysalis Health Center Broward Psychological Services

Main Administrative Office & Outpatient Department 1941 NW 150th Ave
3800 West Broward Blvd. Pembroke Pines, FL 33028
Suite 100Fort Lauderdale, FL 33312 Phone: [phone]
Phone: [phone] Hours: Call for appointment times

Hours: Mon-Fri 9:00am-5:00pm
Memorial Outpatient Behavioral Health Center

3400 North 29^th Ave

Hollywood, FL 33020

Phone: [phone]

Hours: M-Th 8am-9:30pm

Fri 8am-8pm

Saturday, Sun 8:30am-5pm
Monroe County Locations:

Guidance Care Centers:

GCC - Key Largo (Upper Keys) GCC - Key West (Lower Keys)
99198 Overseas Hwy., Suite 5, 1205 Fourth Street
Key Largo, FL 33037 Key West, FL 33040
Phone:[phone] Phone: [phone]
Hours: M-F (8am–5pm) Hours: M-F (8am-5pm)
GCC – Marathon (Middle Keys) Lower Keys Medical Center
3000 41st Street - Ocean, DePoo Medical Building
Marathon, FL 33050 1200 Kennedy Dr. Key West, FL 33040
Phone:[phone] Phone: [phone]
Hours: M-F (8am-5pm) Hours: 24hours assessment center Mon-Sun