Learning Disability Services Registration Information for Students with ADHD

Transcription

1 Learning Disability Services Registration Information for Students with ADHD Dear Student, If you wish to register with Learning Disability Services, you must provide relevant psychological or medical documentation. The attached form is for students who do not have a full psycho-educational assessment which documents their learning needs and how their ADHD impacts their academics. Students who submit this form should be aware that they might be requested to go through additional academic assessment through Learning Disability Services prior to receiving full accommodations. During peak periods it is possible that from the time that your documentation reaches our office, it can take up to a maximum of 2 weeks for you to see your counsellor for your initial appointment. Many accommodations take time to implement. In some cases, students who are approaching us in the middle or near the end of a term might only be able to fully access their accommodations the next term. Extended time for tests/exams needs to be arranged at the start of each academic term. You may find it helpful to read information specific to your disability at In the interim, if you have any urgent questions that are not answered on our website, please do not hesitate to contact our receptionist at (416) who will direct you to the appropriate person. Please note that students enrolled at Glendon College need to contact Counselling & Disability Services, Glendon Site at (416) We are looking forward to working with you. Regards, Maureen Haig, B.Ed., M.A Manager, Learning Disability Services

2 Counselling and Disability Services Learning Disability Services - Medical Documentation for ADHD NOTE: This form must be signed and stamped by a medical practitioner. Please Print. Date Completed (mm/dd/yyyy): / / SECTION TO BE COMPLETED BY STUDENT Student s Last Name: Student s First Name: Student Number: Address: City: Postal Code: Date of Birth (mm/dd/yyyy): / / Phone (Home/Cell): Address: May we contact you by ? Y N SECTION TO BE COMPLETED BY MEDICAL PRACTITIONER Please use office stamp as well as signature: Name: Address: Phone Number:

3 How long have you known this student? Nature of Primary Disability: _ Date of onset/diagnosis: Summary of symptoms. Please be specific. Identify relative strengths of the student: As much as possible please comment on the impact of the student s disability on their academic work Primary Disability is: q permanent a functional limitation that will significantly impact student over course of their academic career q temporary need of academic accommodations while receiving treatment (approx. 1-3 terms) Please list any additional disabilities: Duration and Frequency of Treatment (if applicable): Possible side effects of medication(s) on student s academic performance:

4 Please indicate the potential academic impact of this student s disability(ies) on: Little effect Moderate effect Severe effect Concentration Processing information Retaining information Meeting deadlines Group participation Exam situations If any of the above effects are severe, please elaborate: Are you aware whether or not the student has received any academic accommodations in the past? If so, what were they? I give consent for Disability Services within Counselling and Disability Services to contact my medical practitioner, if necessary, regarding the information provided in this document: Student s Signature: Practitioner s Name (please print): Practitioner s Signature: Medical Practitioner s License Number: **Please ensure that this form is completed in full. Incomplete forms will not be accepted. **Please return completed form to student or fax this form to: Maureen Haig, Manager, Disability Services, (Fax Number). **Note to student: If you have other relevant documentation, you may include copies of them with this registration package. These additional documents are not intended to replace the LDS registration package.please note - additional documentation may be requested.

5 COUNSELLING & DISABILITY SERVICES YORK UNIVERSITY LDS ADHD Student Questionnaire Please print neatly. Date (dd/mm/yyyy): Student Name: Student Number: Student Address: Student Telephone Number (home/cell): Program of Study: q Undergraduate q Masters q Ph.D. q Certificate How did you hear about us? Did you have access to academic accommodations in high school or in elementary school? If so, what where they? Did you complete high school? If so, what year? How did you do academically in high school? What session (fall/winter/summer) and year did you first enroll at York University? Did you come straight from high school to York University? Yes q No q If not, how many years have lapsed since you were in high school? What did you do during those years? Have you been to any other post secondary schools? If yes, please name them, indicate the year(s) you were there and courses, diplomas or degrees completed at these schools. How did you do academically? Are you currently or have you ever been on academic warning at York University? If yes, when?

6 What do you see as your academic strengths? What are your academic challenges? What strategies do you use to assist you in coping with these challenges? How many courses are you currently enrolled in? How is your education being funded (e.g. OSAP, scholarship)? Have you used any computer technology or disability assistive software to support you with your studies? If yes, list what technologies you have used What are your educational goals? How do you think your disability has affected your academic performance and educational goals? Do you have a good relationship with a health professional? If yes, what makes the relationship a good one?

7 Do you have any other social support systems in place? What are your expectations of our program? How to you think your disability/counselor can support you? If at the end of your year, you have had a successful year, what does it look like? Is there anything else we need to know about you that would help us support you in your studies?