NOTICE
a handwritten signature is required at the bottom of this form

This page can be used in either of two ways, CLICK to CHOOSE...

(1) Filled in online by TYPING answers directly into the form, and then printed
-or-
(2) Printed out first, to be filled in by HANDWRITING on the paper copy
UNIVERSITY OF CALIFORNIA at BERKELEY
DISABLED STUDENTS' PROGRAM

260 CESAR CHAVEZ CENTER
BERKELEY, CALIFORNIA 94720
TEL: (510) 642-0518 FAX: (510) 643-9686
WEB: dsp.berkeley.edu
CERTIFICATION OF ATTENTION-DEFICIT DISORDER / HYPERACTIVITY DISORDER

The student named below has applied for services from the Disabled Students' Program (DSP) at UC Berkeley.  In order to determine eligibility for services, we require documentation of the student's Attention-Deficit/Hyperactivity Disorder (ADHD).  After completing this form, please print it out, sign it, and mail or FAX it to the address above.  The information you provide will not become part of the student's educational records and will be kept in the student's confidential file at DSP.  In addition to the requested information, please attach all supportive information, reports, and test results relevant to the documented diagnosis and limitations.

1. Student's Name:  Today's Date:

Month
Day
Year
2. What is your DSM-IV multi-axial diagnosis for this student?

Axis I:
Axis II:
Axis III:
Axis IV:
Axis V (GAF score):
3. Date of above diagnosis:
Month
Day
Year 		4. Date student was last seen:
Month
Day
Year
5. In addition to DSM-IV criteria, how did you arrive at your diagnosis?
Please check all relevant items below, adding brief notes that you think might be helpful to us as we determine which accommodations and services are appropriate for the student.
Structured or unstructured interviews with the person
Interviews with other persons, or questionnaires filled out by them
Behavioral observations
Developmental history
Educational history
Medical history
Psycho-educational testing. Date(s) of testing?
Standardized or nonstandardized rating scales
Other (Please specify):
6. Please provide specific information about the academic limitations and severity of symptoms this student encounters as a result of his/her ADHD.
LIMITATION No
Impact 		Moderate
Impact 		Severe
Impact 		Don't
Know
Organization
Concentration
Activation/initiating to work
Sustained focus
Memory
Stress management
Timely submission of assignments
Understanding directions
Managing internal distractions
Managing external distractions
Specific academic topics:
• Math
• Reading
• Written expression
• Other (please describe):
7. Is this student taking medication(s) for ADHD?
Describe medication(s), date(s) prescribed, effect on academic functioning, and side effects.
Do limitations/symptoms persist even with medications?
8. Other Information...
Is there anything else you would like us to know about this student?
9. Fill in this section by hand on the printed form:



Signature of Professional
Date
Professional's Name (printed) and Title
License No.
Address
Telephone No.
City, State, Zip
Fax