Attention-Deficit/Hyperactivity Disorder (ADHD) Documentation Form
STUDENT NAME: ___________________________________________ STUDENT PHONE: ____________________
STUDENT EMAIL(S):______________________________________________________________________________
STUDENT MAILING ADDRESS: _____________________________________________________________________
STUDENT: Please have this form completed by a qualified professional and return it to the Disability and Learning
Resource Center (address on following page).
To ensure the provision of reasonable and appropriate services for students with ADD/ADHD at The School of the Art
Institute of Chicago, a licensed professional (e.g. physician, psychologist, psychiatrist) must provide current and
comprehensive documentation of the differential diagnosis of the student’s disability. The ADA Amendments Act
views a disability as a physical or mental impairment that substantially limits one or more major life activities, such as:
manual tasks, walking, seeing, hearing, speaking, breathing, learning, thinking, concentrating, or working.
Please complete the following form for ________________________________ who has requested disability-
related services and accommodations from our office. (Please print clearly or type.)
1. DSM-IV Diagnosis and comorbid conditions, if any: _________________________________________
2. Date of Diagnosis: ____________________________________________________________________
3. Date of your last contact with the student: ________________________________________________
4. What instruments/procedures were used to diagnose ADD/ADHD?
5. Please describe the current symptoms of this disorder. What is the expected duration, stability, and/or progression of
this disorder?
6. Please briefly describe the current treatment, including medications. Describe any possible side effects of the medication.
