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Criteria for Documentation of ADD/ADHD Disorders

  1. Student Name
  2. Social Security Number
  3. Date of Birth
  4. Date of Evaluation
  5. DSM Diagnosis
  6. Level of severity (mild, moderate, severe)
  7. Diagnosis criteria (attach test results/report)
  8. Describe the functional nature of this impairment.
  9. Is the impairment stabilized or does it fluctuate?
  10. Does the student have other accompanying impairments such as depression or learning disabilities, etc.?
  11. Describe current medication and possible side effects.
  12. Describe the student’s functional limitations in an educational setting.
  13. Does the student continue to need accommodations when utilizing recommended medications?
  14. What are your recommendations regarding academic accommodations for this student?
  15. Name, signature, and title of evaluator
  16. Date