Healthcare Provider Report Form: Medical Leave of Absence

Healthcare Provider Report Form: Medical Leave of Absence

Northwestern University Counseling & Psychological Services (CAPS) asks that students requesting a medical leave of absence (MLOA) share this form with any of their current treatment provider(s). This form will be used to inform the treatment recommendations CAPS makes for a student's MLOA.

For additional information about MLOAs:

https://www.northwestern.edu/studentaffairs/sass/medical-leave/index.html

https://www.northwestern.edu/counseling/clinical-services/medical-leave-of-absence/