Download Verification of Disability for Attention Deficit Hyperactivity Disorder

Verification of Disability for Attention Deficit Hyperactivity Disorder
DISABLED STUDENTS PROGRAMS AND SERVICES - MIRACOSTA COMMUNITY COLLEGE
I. Release of Information
Date: _____________________
To: __
__________________________________________________________________
(Name of psychiatrist/physician/specialist who can provide verification of ADHD)
Address: ____________________________________________________________________
City: _________________________________ State: ______________ ZIP:_______________
I request that the professional designated above complete this form, and hereby authorize you
to release to Disabled Students Programs and Services at MiraCosta Community College, any
information from your records which bears on the medical or health conditions and/or
educational development pertaining to me. All information will be kept confidential and
maintained as a part of my records with the DSPS office at the college.
Student’s Name (print): _________________________________________________________
Signature: ___________________________________________________________________
Date of Birth: _____________________ Last 4 digits of Social Security #: _________________
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II. Verification of Disability
MiraCosta College requires that the following criteria, consistent with the DSM IV, be met in
documenting ADHD in adults. Without such written documentation, the student will be unable to
receive the appropriate accommodations critical to his/her success. You may attach a narrative
report in lieu of completing this form. Please indicate each criterion that is applicable to this
student and attach supporting data (e.g. copies of rating scales). Assessment on which the
documentation is based must have been completed no more than 3 years prior to the
student’s application for academic assistance, or must have been completed as an adult (18
years or older) and still be considered current. Thank you for your assistance.
1. Developmental History and family history of ADHD symptoms and problem behaviors
across multiple settings, documented using several independent sources (such as past
evaluations, school records, teacher reports, parent reports). Evidence and Source:
_________________
______________________________________________________________________
2. Current Symptoms that meet DSM IV diagnostic criteria (possible data sources include
clinical interview, behavior rating scales). Evidence and Source:___________
_______________________________________________________________________
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3. Interference with Learning such as academic social or vocational functioning.
Evidence and Source:
4. History of Interventions. List any medications, therapy or other treatment that the student
has used and currently using in an attempt to mitigate symptoms. Evidence and Source:
5. Diagnosis:
Current Medication(s):
____________________________________________________________________________
Secondary Diagnosis:
Date of Assessment:
Doctor’s Signature: