Fill - Free fillable ADHD-Documentation-Form ADHD Documentation Form PDF form

PO Box 1129 • Eunice, LA 70535

Science Building Room 145

337-550-1204 • Fax 337-550-1268

www.lsue.edu/studentaffairs • ods@lsue.edu

JANUARY 2019

ATTENTION DEFICIT/HYPERACTIVITY

DISORDER (ADHD)

DOCUMENTATION REQUEST FORM

(TO BE COMPLETED BY QUALIFIED PROFESSIONAL)

When completing this form, please PRINT or TYPE and COMPLETE ALL FIELDS.

Incomplete forms will not be accepted.

**** If you have a formal evaluation, please attach the documentation.****

This student is requesting an auxiliary aid or service, academic adjustment, and/or other accommodations from

Disability Services. In order to consider this request, as well as to ensure the provision of reasonable and appropriate

auxiliary aids and services, University Policy requires that a Qualified Professional provide current and comprehensive

documentation of the disability. A qualified professional includes a licensed psychiatrist, psychologist, medical doctor,

or other qualified medical or mental health professional who is not a family member of the student. IN ORDER TO BE

CONSIDERED CURRENT, THE QUALIFIED PROFESSIONAL’S EVALUATION MUST BE WITHIN THREE (3) YEARS PRIOR TO

THE DATE OF THE MOST RECENT REQUEST FOR DISABILITY ACCOMMODATIONS.

Student’s Name: _____________________________________ LSUE ID Number: ____________________

Date of Birth: ____________________________________________________________________________

Mailing Address _____________________________________ City & Zip Code _______________

Phone Number: _____________________________________________________

1. Diagnosis (as diagnosed by the DSM-5): ___________________________________________________________

2. Date of Diagnosis: _____________________ Date of Last Contact with Student: _________________________

3. For the purpose of determining academic adjustments, describe the severity and longevity of the substantial

limitations due of AD/HD.

JANUARY 2019

ATTENTION DEFICIT/HYPERACTIVITY | DISORDER (ADHD) | DOCUMENTATION REQUEST FORM | Page 2

4. List current medication, along with any current side effects that may impact academic performance:

5. Describe the student’s functional limitations in an educational setting (i.e., current and/or anticipated problems

associated with the condition):

6. Please indicate the RECOMMENDATIONS you have regarding reasonable and appropriate auxiliary aids or

services, academic adjustments or other accommodations to ensure equity for the student’s academic success

based on the functional limitations indicated above.

Please check all that apply: ___ Extended Time (1.5X) ___ Distraction Reduced Environment

___ Audio Recorded Lectures

Please note: If any other accommodations are being requested, additional documentation WILL BE

REQUIRED.

Qualified Professional’s Signature: _______________________________________________

Printed Name & Title: __________________________________________________________

Office Telephone Number: _____________________________________________________

Address ______________________________________________ City & Zip _____________________

Date: _________________________________________________________________________

Submit this form and all necessary documentation via scan/email, fax, mail, or in person to:

Office of Disability Services

Louisiana State University Eunice

PO BOX 1129 • Eunice, LA 70535 • Science Building Room 145

Phone: 337-550-1204 • Fax: 337-550-1268

JANUARY 2019

Email: ods@lsue.edu

REQUEST FOR ACCOMMODATIONS

(TO BE COMPLETED BY STUDENT)

Student’s Name: _______________________________________________________________________________

Date of Birth: _________________________________________ LSUE ID Number: _______________________

Mailing Address ________________________________________________________________________________

City & Zip Code __________________________________________

Phone Number: ________________________________________________________________________________

I am requesting accommodations because I have been diagnosed with one or more of the following disabilities

which functionally impairs my ability to perform in an academic environment: (Check all that apply)

___ Attention Deficit/Hyperactivity Disorder ___ Learning Disability

___ Psychological Disability ___ Deaf & Hard of Hearing

___ Physical or Systemic (Medical) Disability (specify): _________________________________________

In the space below, list and explain the reason for each of the accommodations you are requesting. What

accommodations, if any, have you received in the past (i.e. during high school etc.) Please be as specific as possible.

Signature of Student: ______________________________________ Date: ______________________________

NOTE: The Office of Disability Services does not provide copies of any documentation. ODS strongly

recommends maintaining copies of any submitted documentation for your personal records.

Fill Online, Printable, Fillable, Blank ADHD-Documentation-Form ADHD Documentation Form Form

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Fillable ADHD-Documentation-Form ADHD Documentation Form

Fill Online, Printable, Fillable, Blank ADHD-Documentation-Form ADHD Documentation Form Form

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