Name of student

Email/phone

Date of ODS initial screening

ODS staff member

Referred by

Reason for referral

The student listed above has been provided with an initial screening for a possible learning disability and/or ADD/ADHD. At this time, ODS would/would not (circle one) recommend that the student proceed with a complete psychoeducational evaluation. The guidelines for LD testing Documentation of a Learning Disability/Attention Deficit Disorder can be found on the ODS website @ www.barnard.edu/ods under the link ODS manual and forms and please remember that all testing must satisfy the five criteria listed in the guidelines. The ODS website also has a referrals handout, ODS Referrals List for LD/ADD Testing, which should be used in selecting a clinician in the NYC area. Students who wish to be tested outside the NYC area should make sure that they and their clinicians are familiar with the above-mentioned guidelines.

Please check one of the applicable statements below:

___I will use one of the clinics/clinicians recommended by ODS and have selected:_____________________________________________

___I will use an outside clinic/clinician__________________________

and give permission for Susan Quinby, Director of ODS or Olga (Okie) Hrycak, LD Coordinator to contact my clinic/clinician. I will provide my evaluator with the ODS testing guidelines.

Name of student (print)

Student signature