ANU Verification Form

NOTE: This form is to be filled out, in its entirety, by a professional who is currently treating the student. This professional must be unrelated to the student, and any information provided by a family member will be considered supplemental. You will be emailed an electronic copy of this information upon submission.

Student Information
Student Name Student Name First Last
Provider Information
Provider Name Provider Name First Last
Title
License/Certification Number and Issuing State
Provider Email
Provider Address Provider Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Professional Visit Summary
Date of Initial Contact with Student Date of Initial Contact with Student / MM / DD YYYY
Date of Most Recent Formal Contact with Student Date of Most Recent Formal Contact with Student / MM / DD YYYY
Approximate Frequency of Contact with Student since Initial Contact
Date of Completion of Form Date of Completion of Form / MM / DD YYYY
Student Disability Information
Please describe the student's disability, listing a diagnosis (if applicable). Include the date of diagnosis and explain the evaluations/labs/tests administered used in the diagnostic process.
Please attach a copy of any psychoeducational reports, neuropsychological evaluations, or test results if available.

Attach Files
List any major life activities that are impacted by the student’s disability and indicate severity (substantial, moderate, mild). Examples of major life activities might include an impact in areas such as reading, writing, seeing, hearing, concentrating, learning, walking, lifting, etc.
Provide a summary of student’s present symptoms and indicate severity (substantial, moderate, mild).
Describe any disability-related barriers or educational impacts that may need to be addressed in the university setting to ensure the student with a disability has equal access to course content in comparison to their non-disabled peers. Examples: in-person courses, online courses, labs, clinical setting, internships, etc.
Describe the expected duration of the student’s condition (progression, prognosis, stability, etc.).
If the student experiences episodic flare-ups due to the condition, please describe triggers, the frequency, and duration of the flare-ups.
Describe medications prescribed to the student and any side effects that may impact the students learning experience resulting from treatments or medications.
Has the student signed a Release of Information?

Has the student signed a Release of Information? Yes No
Certification
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Email

ANU Verification Form

ANU Verification Form

Student Information

Provider Information

Professional Visit Summary

Student Disability Information

Certification