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Letter for requesting ADHD documentation

Dear Doctor:
The Regents Centers for Learning Disorders of the University System of Georgia require that the following criteria, consistent with the DSM-IV, be met in documenting ADHD in adults. Without such written documentation, a student will be unable to receive appropriate academic accommodations that may be critical for his/her success. If you prefer to use this form rather than a narrative report, please indicate each criterion that is applicable to this student. You must attach copies or summaries of the specific questionnaires, measures, or clinical data used to establish each criterion, and include your signature.

Student’s Name: ___________________________________________
Student’s SS#: ___________________________________________

1. [ ] yes [ ] no Reported history of symptoms of ADHD by the age of seven, corroborated by an independent source.
2. Possible data sources: Clinical interview, past psychological evaluations, parent report, teacher report, behavior rating scale developed by parent.
   Actual Data provided: ________________________________
3. [ ] yes [ ] no Self report of six or more current symptom from the DSM-IV criteria for ADHD.
   Possible data sources: Clinical interview, behavior rating scales.
   Actual Data provided: ________________________________
4. [ ] yes [ ] no Documentation of both childhood and current adult behavior on rating scales of ADHD symptoms that have appropriate age norms.
   Possible data sources: Norm based behavior rating scales.
   Actual Data provided: ________________________________
5. [ ] yes [ ] no Corroboration of current ADHD symptoms across multiple setting by two independent observers with knowledge of the student’s functioning (e.g. parent, spouse, teacher, supervisor, co-worker, relative, and/or clinical observations).
   Possible data sources: Significant other interview (in person or by phone), behavior rating scale completed by significant other, classroom observations, clinical observations.
   Actual Data provided: ________________________________
6. [ ] yes [ ] no Clear evidence of interference with developmentally appropriate academic or social functioning.
7. [ ] yes [ ] no Schizophrenia, borderline personality disorder, autism or mental retardation are not the primary disability, nor are mood disorder, anxiety disorder, or substance abuse the primary causes of reported ADHD symptoms. Assessment of their differential diagnoses must be documented.
   Possible data sources: Clinical interview, self-report checklists of psychiatric symptoms, personality assessment measures.
   Actual Data provided: ___________________________________
8. [ ] yes [ ] no Assessment on which documentation is based must have been completed no more than three years prior to the student’s application for academic assistance, OR must have been completed as an adult (18 years).
   Date of assessment: _______________________________________
   Current Medication: _______________________________________

Additional information (and recommended accommodations):

Signature: _______________________________________
Date: __________
Name: __________________________________________
Address: ________________________________________
________________________________________________
________________________________________________
Office Phone: ____________________________________

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