____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Disability Services
ATTENTION DEFICIT/HYPERACTIVITY DISORDER
(AD/HD) DOCUMENTATION REQUEST FORM
****This form must contain ALL of the REQUESTED INFORMATION and be TYPED or
PRINTED in order to apply for accommodations through Disability Services.****
Student’s Name: _______________________________________________________________________________
Date of Birth: _________________________________________________________________________________
Address: _____________________________________________________________________________________
Phone Number: _______________________________________________________________________________
B#: _________________________________________________________________________________________
This student is requesting an auxiliary aid or service, academic adjustment, and/or other accommodations from the
Disability Services due to AD/HD. In order to consider this request, as well as to ensure the provision of reasonable
and appropriate auxiliary aids and services, College Policy requires that a Qualified Professional provide current and
comprehensive documentation of AD/HD. A qualified professional includes a licensed psychiatrist, psychologist,
medical doctor, or other qualified mental health professional who is not a family member of the student. IN ORDER
TO BE CONSIDERED CURRENT, THE QUALIFIED PROFESSIONAL’S STATEMENT MUST BE WITHIN 3
YEARS PRIOR TO THE DATE OF THE MOST RECENT REQUEST FROM DISABILITY SERVICES.
The documentation provided must include information that diagnoses the AD/HD, describes the functional
limitations in an educational setting, and indicates the severity and longevity of the AD/HD for the purpose of
determining academic adjustment(s) or other accommodation(s).
To facilitate the gathering of such critical information, please respond to the following and return to SOWELA,
Disability Services.
1. Diagnosis (as diagnosed by the DSM-IV): _______________________________________________________
2. If you have a formal evaluation, please attach it.
3. Date of Diagnosis: ___________________ Date of Last Contact with Student: ______________________
4. Provide a summary of the student’s educational, medical, and family history that may relate to AD/HD (must
demonstrate that difficulties are not the result of sensory impairment, serious emotional disturbance, cultural
differences, or insufficient instruction):
5/2012 1
