College Student Information Form
Name
First Name
Last Name
Nickname
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
-
Area Code
Phone Number
Cell Phone Number
-
Area Code
Phone Number
School Name
School Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Academic Advisor
Academic Advisor Phone Number
-
Area Code
Phone Number
Primary Health Care Provider
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
-
Area Code
Phone Number
Mental Health Provider
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Parent 1 Name
Occupation/Employer
Home Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Email Address
example@example.com
Parent 2 Name
Occupation/Employer
Home Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Email Address
example@example.com
Guardian Name (if applicable)
Occupation/Employer:
Home Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Email Address
example@example.com
When was ADHD diagnosed?
Type of ADHD?
Name of Diagnostician
Are there any known learning disabilities or co-morbid conditions? If yes, please explain.
Are you currently taking medication for ADHD or any other related difficulty, such as depression or anxiety? If yes, which medication(s) and how often?
Other medical conditions, including current treatment and medications?
Do you have special accommodations per an IEP/504 Plan? If yes, please describe and upload a copy.
Upload copy of IEP/504 plan here
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Have you ever worked with a coach or organizational consultant to work with ADHD or LD problems? If yes, what was the focus of the work?
Are there other family members with an ADHD diagnosis? If yes, what is their relationship to you?
Is there any family history or substance abuse?
What are your interests, hobbies, strengths? Please brag about yourself!
Please list or attach your class schedule for the current or upcoming semester
Upload class schedule here
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Please list your extracurricular activities, on and off campus.
On a scale of 1-10, how well do you and your family understand ADHD?
Hover for explanation of numbers
May I ask your parents to review this form for accuracy? Sometimes students don't remember the full history.
Yes, with no restrictions
No, please don't
Only review the following questions with my parents.
Only review these questions with my parents:
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