Form D - Attention Deficit-Hyperactivity Disorder Verification - Idaho State Bar


Form D
Page 1
Idaho State Bar
525 West Jefferson, PO Box 895, Boise, ID 83701
Phone: (208) 334-4500
Fax: (208) 334-2764
Attention Deficit-Hyperactivity Disorder Verification
Form D and accompanying documentation must be submitted with a completed Form A to the Idaho State Bar.
This form must be completed by a licensed Psychologist or Neuropsychologist with specialized
expertise in the assessment of learning disabilities.
The Idaho State Bar requires that an applicant with a specific learning disability must have been identified
by a psycho-educational assessment process that includes data from both cognitive and achievement
measures listed below. The evaluation should specify whether combined type, predominantly inattentive
type, or predominantly hyperactive-impulsive type. Test results should: (1) Have been administered
within the last three years; (2) Identify normative academic skills deficits(s); (3) Identify normative
information processing deficits(s); (4) Certify that the applicant’s intellectual ability is within the normal
range of functioning or higher. The diagnostic report must include copies of the evaluation and a
thorough battery of age-appropriate psychological tests and test scores administered within the last three
years from the date the application for reasonable testing accommodations is filed. The test scores
obtained and the interpretations of these scores must provide evidence of the current impairment and
establish a rationale that supports the need for specific accommodations.
Applicant Name: (Please print name)
Licensed Health Care Professional
Name and License Number:
(Please print name)
Telephone Number
Please Include The Following Information In Your Report:
Please attach a copy of the completed report with this document along with all test scores.
1. List the credential(s) that qualify you to diagnose and/or verify the applicant’s disability and to
recommend accommodations.
2. How does the applicant’s disability currently present itself?
3. What is the academic and developmental history of the disability? (Attach any relevant
documents; e.g., assessment summaries, Individual Education Plans from earlier records, grade
transcripts, etc.)
4. List relevant family history.
5. What remediation has been attempted and what were the results?
6. Were other diagnoses or conditions ruled out as the primary cause of academic skills deficits (e.g.,
anxiety, psychological disturbance, etc.)?
7. What fundamental limits does the disability impose (e.g., occupationally, socially, and


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