Verification Form: Attention-Deficit/Hyperactivity Disorder

NOTE: This form is to be filled out, in its entirety, by the professional who is treating the student. This professional must be unrelated to the student, and any information provided by a family member will be considered supplemental. Forms with insufficient detail will prompt a request for more information. PLEASE TYPE AND SUBMIT THIS FORM ELECTRONICALLY, rather than hand-writing or printing it out. You will be copied electronically upon submission.

Student Information
Student Name Student Name First Last
Certified Provider Information
Provider Name Provider Name First Last
Provider Email
Provider Title
License/Certification Number and Issuing State
Provider Address Provider Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Fax Fax - ### - ### ####
Professional Visit Summary
Date of Initial Contact with Student Date of Initial Contact with Student / MM / DD YYYY
Date of Most Recent Formal Contact/Appointment with Student Date of Most Recent Formal Contact/Appointment 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
Diagnostic Information
Date of Diagnosis Date of Diagnosis / MM / DD YYYY
List the diagnostic procedures, assessments, and scales used to make the diagnosis. (A complete psychoeducational or neuropsychological evaluation is preferred in lieu of completing this form.)
Age at onset of symptoms:
Describe the settings in which these symptoms have been most evident.
Differential diagnosis: Explain how other psychiatric or medical disorders that may cause problems with inattention and/or hyperactivity-impulsivity were considered, evaluated, and documented or ruled out. Please also discuss any alternative or coexisting conditions.
Treatment Information
Medications
Current medication(s) including dosage, effectiveness, and side effects:
Date of most recent medication change and compliance with medication plan:
Educational and Behavioral Interventions
What academic interventions, coaching support, or other behavioral programs have been made available, and what was their level of effectiveness?
Impact of Condition on Educational Success
Identify the specific academic abilities or functions that are compromised by the disorder, and indicate severity of these limitations:
Suggested Accommodations

NOTE: Final determination of appropriate accommodations will be determined by AccessibleNU in accordance with the mandates of the Rehabilitation Act of 1973 and the Americans with Disabilities Act as well as court rulings and Department of Education Office of Civil Rights rulings related to these two laws. Each recommended accommodation must be accompanied by an explanation of its relevance to the diagnosed disability.
Extended time for exams?

Extended time for exams? Yes No
Explanation of relevance/justification:
Quiet room in which to take exams?

Quiet room in which to take exams? Yes No
Explanation of relevance/justification:
Other recommended accommodations (please specify in the field below):

Other recommended accommodations (please specify in the field below): Yes No
Other accommodation(s) and explanation/justification (if applicable):
Certifying Authority
Using your mouse or finger, draw your signature in the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY

Verification Form: Attention-Deficit/Hyperactivity Disorder

Verification Form: Attention-Deficit/Hyperactivity Disorder

Student Information

Certified Provider Information

Professional Visit Summary

Diagnostic Information

Treatment Information

Educational and Behavioral Interventions

Impact of Condition on Educational Success

Suggested Accommodations

Certifying Authority