Health Care Provider Report: Medical Leave of Absence

Health Care Provider Report: Medical Leave of Absence

Student Instructions: Share the link to this form with each of your treatment providers at your first session (or assessment session). We recommend you also provide a copy of your MLOA recommendations letter from the Dean of Students Office.

Treatment Provider: Please complete this form and submit it electronically. You have the option to save your work and resume at a later time.

-We are interested in obtaining information about your work with the student and the progress made.

-Given the rigor and challenges of the academic and social environment to which the student will return, we would like to know whether you feel the student is healthy enough to continue pursuing education, in this setting, at the current time.

-It is important that we have as much information from you as is possible so we can support the student’s success upon return.

-If the student has been in a hospital, PHP, IOP or treatment program, please include initial evaluations and discharge summaries (which can be uploaded below).

-IF YOU NEED A COPY OF THIS REPORT FOR YOUR RECORDS, PLEASE PRINT THE PREVIEW PAGE BEFORE SUBMITTING.