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/

Student's Name Student's Name First Last
Treatment Provider Name Treatment Provider Name First Last
Treatment Provider Phone Treatment Provider Phone - ### - ### ####
Treatment Provider Email
Treatment Provider License #
State/Location Where Licensed
Please briefly summarize or list the clinical issues of focus in the student's treatment with you.
At this time, do you believe that a MLOA from Northwestern (typically a duration of two academic quarters) could be beneficial for this student's recovery?

At this time, do you believe that a MLOA from Northwestern (typically a duration of two academic quarters) could be beneficial for this student's recovery? Yes No
If you answered "no" to the previous question, please elaborate.
Below is a list of typical treatment recommendations CAPS may provide when a student pursues a MLOA. Please check any that you think may be beneficial for the student's MLOA.

Below is a list of typical treatment recommendations CAPS may provide when a student pursues a MLOA. Please check any that you think may be beneficial for the student's MLOA. Receive an evaluation at a program offering intensive outpatient and partial hospitalization programs. Follow all treatment recommendations. After stepping down through the program, continue weekly, individual psychotherapy through the reinstatement process. Participate in a minimum of weekly, individual psychotherapy for the entire period of your medical leave and through the reinstatement process. Receive a comprehensive evaluation at a licensed substance abuse treatment facility. Follow all treatment recommendations including any after-care treatment or recommendations through the reinstatement process. Receive a psychiatric evaluation to see if medication may be helpful for your concerns. Continue to work with a psychiatrist and follow all treatment recommendations regarding medication management. Implement a program of behavioral activation (20 hours a week or more of structured activity outside the home). This may include, work or volunteer activity.
Please share any additional comments or recommendations that you have for the student's MLOA that are not listed above.
Treatment Provider Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY