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.

1Information > 2Instructions for Completing a Release of Information Form > 3Review Your Entry
Student Name Student Name * First Last
Student Date of Birth Student Date of Birth * / MM / DD YYYY
Student's Campus (For undergraduate students, please indicate Evanston. Graduate and professional students may be affiliated with programs on either campus.)

Student's Campus (For undergraduate students, please indicate Evanston. Graduate and professional students may be affiliated with programs on either campus.) Chicago Evanston
Initial Diagnosis *
Current Diagnosis *
TREATMENT MODALITY

Please check all that apply to your contacts with student.
*

Individual therapy Group therapy Day treatment Individual nutrition counseling Intensive outpatient (IOP) Partial hospitalization (PHP) Substance abuse treatment program Medication management Residential
If psychotropic medication(s) was prescribed, did the student adhere to treatment? *

If psychotropic medication(s) was prescribed, did the student adhere to treatment? Yes No
Please list all psychotropic medication(s) that were prescribed along with dosage(s). (If no medications were prescribed, please indicate "N/A.") *
DURATION OF TREATMENT (if individual or group)
Date of first visit after student's medical leave began Date of first visit after student's medical leave began / MM / DD YYYY
Date of most recent visit Date of most recent visit / MM / DD YYYY
Total number of visits
DURATION OF TREATMENT (if treatment program)
Name of program
Date of admission Date of admission / MM / DD YYYY
Date of discharge Date of discharge / MM / DD YYYY
TERMINATION
Has the student terminated treatment with you or your program? *

Has the student terminated treatment with you or your program? Yes No
Was the termination mutual and planned? *

Was the termination mutual and planned? Yes No If yes, what was the discharge plan? If no, please explain.
Save my progress and resume later
Enter Your Email Address *

A special link to resume the form will be sent to your email address.