DISABILITY RESOURCE CENTER
VERIFICATION OF AN AUTISM SPECTRUM DISORDER
Student Questionnaire
The first eight pages are to be completed by the student. Some of the questions may not apply to your situation.
Please label them “not applicable.”
Name: ____________________________________________________________________________________
Date of Birth: ____________________________________
Year in College:
Student ID: __________________________
□ Freshman □ Sophomore □ Junior □ Senior □ Masters □ Doctorate
□ Post Baccalaureate □ Non-Degree Undergraduate □ Non-Degree Graduate
Local phone: (_______) _________________________
Cell phone: (_______) _______________________
Address: __________________________________________________________________________________
Academic Information
1. Provide a description of your diagnosis. What symptoms do you experience?
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2. What types of services/accommodations have you used in the past and were they helpful?
Services
Extended Time on Exams
Reader/Scribe
Books on CD
Notetakers
Tutoring
Personal Counseling
Used?
Helpful?
Comments
3. What are your academic strengths?
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4. What are your academic weaknesses?
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5. How does your disability impact you in a classroom setting (i.e. listening, note-taking, communication,
writing, computer skills, sitting or attendance)?
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6. How does your disability impact you on evaluations (e.g. tests, papers, oral reports or group projects)?
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7. How does your disability impact you when doing out-of-class assignments (e.g., reading, writing,
calculating, typing, research)?
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8. What will impact your success in college? What barriers do you see in you being successful? (e.g., skills,
motivation, goal-setting, confidence, outside commitments, etc.)
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9. List the accommodations you are requesting in an academic setting, if applicable.
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Medication
1. What medications are you currently taking?
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2. How will you obtain them while at College?
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Housing Needs
1. Describe your current living arrangement (i.e., with parents, in dorm, with roommate etc.)
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2. Where do you plan to live while attending college? With whom?
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3. Describe your living habits (i.e., privacy, personal space needs, orderliness, etc.)
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Support Network
1. Who will be the support persons available to you on an ongoing basis while you are at college? Examples:
parent, spouse, therapist/counselor, coach, etc.
_________________________________________________________________
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2. What kinds of things do these people currently provide for you (i.e., what roles do each play)?
_________________________________________________________________
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3. Do you obtain services from the Division of Rehabilitation Services? If so, what do they provide for you?
_________________________________________________________________
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Sensory Integration
1. Are you sensitive to certain stimuli?
___ Lights or visual disturbance: ___________________________________________________________
___ Odors: ____________________________________________________________________________
___ Noise: ____________________________________________________________________________
___ Touch: ____________________________________________________________________________
___ Tastes/Textures: ____________________________________________________________________
___ Other - Please explain: _______________________________________________________________
Stress Tolerance
1. What particular situations trigger a stress response in you?
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2. What do you do, or what will others see, when you become fearful, angry or frustrated?
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3. Do you use manipulates, comfort objects, or repetitive behaviors to reduce your stress or anxiety? If so,
please describe.
_________________________________________________________________
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Please rate on a scale from 1-10 your ability to manage the stress of the following day-to-day situations you
may encounter as a student.
“No big deal” = 1-2
“I’d be anxious but OK” = 5-6
“I would be very angry or scared and it would be impossible for me to continue” = 9-10
___ The seat you usually sit in is taken when you get to class.
___ You have to look for a different parking spot every day.
___ The professor has left a note on the classroom door explaining that class will be held in an alternative
building today.
___ You are called upon in class to discuss a reading with a student next to you.
___ The bookstore does not have the book you need when you arrive to purchase it.
___ Your professor announces a pop quiz when you enter the room.
___Your roommate ate food that belonged to you which was in your shared refrigerator.
___ The bus you are riding forgets to stop at your stop to let you off.
___ You must walk through a very crowded hallway every time you need to get to your classroom.
___ The grade you get on your first paper (you thought was A quality) is a C- and the professor instructs
you to see him about it.
Fine Motor/Dexterity
1. Do you use a computer? _____________
3. Is your handwriting legible? Slow? ______________
2. Do you own a laptop? ______________
4. Do you take good notes during a lecture? __________
Spatial Issues
1. Do you have trouble recognizing people’s faces? _____________________________
2.
Do you have difficulty navigating different environments or remembering directions? If so, what strategies
do you use to help you? (maps, photos, etc.)
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Social Issues
1. Do you prefer spending time with your friends or spending time alone?
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2. What activities do you like to do with others? (movies, computer games, baseball, etc.)?
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3. When interacting with others, do you have difficulty:
 monitoring your voice level?
 knowing when to start or stop talking?
 knowing how to begin, maintain or end a conversation?
 making eye contact with others while talking?
4. How do you prefer to communicate (email, phone, in person) with the following groups:
 instructors or support persons? ____________________________________________

other students? _____________________________________________________

friends and/or family? _________________________________________________
Time Management/Organization Issues
1. Do you have difficulty starting projects or papers?
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2. Do you have trouble using or structuring free time?
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3. Do you have difficulty making appointments, remembering them or getting to them? If so, describe.
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4. Do you use a planner or other organizational system?
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5. How do you decide on the importance or priority of tasks? (i.e. studying different subjects)
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6. Is your work/study area organized/neat or disorganized/messy?
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7. Do you have a particular hobby or specific area of interest? Please describe.
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Disclosure/Advocacy
1. Whom do you plan to inform of your diagnosis at Arizona State University?
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2. What do you think your greatest challenge or barrier to success at the University will be?
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3. Is there any additional information about yourself that you would like Disability Services to know?
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DISABILITY RESOURCE CENTER
VERIFICATION OF AN AUTISM SPECTRUM DISORDER
This form is intended to assist in meeting our documentation requirements for these disabilities.
However, if not thoroughly completed, it may not be sufficient as the sole form of
documentation provided. Please refer to the “Guidelines for Documenting Autism Spectrum
Disorders” for comprehensive documentation requirements and additional information. To
ensure the provision of reasonable and appropriate accommodations, students requesting services
must provide current (within the last 3 years) documentation of the disability. This
documentation should provide information regarding the onset, longevity and severity of
symptoms, as well as the specifics describing how it has interfered with educational
achievement. Please include a copy (including test scores) of any relevant psychoeducational or
neuropsychological reports. To standardize our gathering of information, it is recommended that
you complete the following questions, even if the material has already been included in your full
evaluation. All information will be kept confidential. Please feel free to contact DRC at (480)
965-1234 with questions.
I request and authorize The Arizona State University Student Health Services (SHS), ASU Counseling Center,
ASU Disability Resource Center, and/or my off-campus provider ____________________________________
to release, fax, mail or discuss with each other information related to my registering with the Disability
Resource Center (DRC).
__________________________________________________________________________________________
Student Name (Please Print)
__________________________________________________________________________________________
Student Signature
Date
The information below is to be completed and signed by the Provider.
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VERIFICATION OF AN AUTISM SPECTRUM DISORDER
1. Please list all DSM-IV or ICD Diagnoses (text and code):
AXIS I:
AXIS II:
AXIS III:
AXIS IV:
AXIS V (GAF score) optional:
a) Date diagnosed:
________ / ________ / ________
b) Date of your last clinical contact with student:
________ / ________ / ________
2. Evaluation
a) How did you arrive at this diagnosis? Please check all relevant items below, adding brief notes that you
think might be helpful to us as we determine eligibility for accommodations.
□
□
□
□
□
□
Structured or unstructured interviews with student.
Interviews with other persons (i.e. parent, teacher, therapist).
Behavioral observations.
Neuropsychological testing. Attach documentation.
Psych educational testing. Attach documentation.
Other (Please specify). _________________________________________________
b) Current treatment being received by student:
□
Medication management:
Current medications: ______________________________________________________
□
Outpatient therapy:
Frequency: ______________________________________________________________
□
Group therapy:
Frequency: ______________________________________________________________
□
Other (please describe):
_______________________________________________________________________
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c) Approximate onset of diagnosis:
□
□
□
□
Child- approximate age:____________
Adolescent- approximate age: __________
Adult- approximate age:____________
Unknown
Severity of symptoms
□
□
□
Mild
Moderate
Severe
Prognosis of disorder:
□
□
□
good
fair
poor
Please explain: _________________________________________________________________
_____________________________________________________________________________
3. Functional Limitations: Should be determined WITHOUT consideration of mitigating measures (i.e.
medication, etc.). If condition is episodic in nature, level of functioning should be assessed based on active
phase of symptoms.
a) Does this condition significantly limit one or more of the following major life activities?
No Impact
Moderate
Impact
Substantial
Impact
Don’t Know
Communicating
Concentrating
Hearing
Learning
Manual Tasks
Reading
Seeing
Thinking
Walking
Working
Other:
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b) Please check the functional limitations or behavioral manifestations for this student:
Not an Issue
Moderate Issue
Substantial
Issue
Don’t Know
Understanding Nonverbal
Behaviors
Peer Relationships/Emotional
Expression
Cognitive Processing
Memory
Processing Speed
Meeting Deadlines
Attending Class
Organization
Reasoning
Stress
Sleep
Appetite
Other:
c) Please describe in detail any functional limitations that fall into the substantial range.
_______________________________________________________________
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d) Special considerations, e.g. medication side effects:
_______________________________________________________________
_______________________________________________________________
e) COURSE LOAD REDUCTION: Is the student’s condition such that it may require them to take
fewer than what is considered a full-time course load?
□
□
□
Yes
No
I don’t know
If YES please explain: ____________________________________________________________________
______________________________________________________________________________________
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4. Accommodations
a) Please mark whether student has utilized accommodations in the past.
□
□
□
Yes - Please describe:_______________________________________________________________
No
Don't Know
b) (Optional) Recommended educational accommodations:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
c) (Optional) Please provide any additional information you feel will be useful in determining the nature
and severity of the student’s disability, and any additional recommendations that may assist in
determining appropriate accommodations and interventions:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Thank you for your help in providing this information so that we may begin services as soon as possible. Please
complete the provider information below. This form should be signed and returned via fax or mail to the DRC
office at the address shown at the end of this document. All documentation submitted to DRC is considered
confidential.
Provider Information
I certify, by my signature below, that I conducted or formally supervised and co-signed the diagnostic
assessment of the student named above.
Signature: _________________________________________________ Date: __________________________
Print Name and Title: ________________________________________________________________________
__________________________________________________________________________________________
State of License: __________________ License Number: ___________________________________________
Address: __________________________________________________________________________________
Street or P.O. Box
City
State
Zip
Phone:______________________________________ Fax: _________________________________________
Please return this form, signed and sealed, to:
Scottsdale Community College
Disability Resources & Services
9000 East Chaparral Road
Scottsdale, Arizona 85256-2626
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