Healthcare Provider Report Form: Medical Leave of Absence

Northwestern University students requesting a medical leave of absence (MLOA) are asked to share this form with their current treatment provider(s). This form will be used to inform a recommendation as to whether the student's MLOA should be granted.

The purpose of a voluntary medical leave of absence is to provide students time away from campus for treatment of a physical or mental health condition that impairs a student’s ability to function safely and successfully as a member of our community. A voluntary MLOA is processed through the Dean of Students office. Each leave is individualized based on the needs of the student and handled on a case-by-case basis.

For more information about MLOA:
https://www.northwestern.edu/studentaffairs/sass/medical-leave/

Student Information
Student's Name Student's Name First Last
Student's Date of Birth Student's Date of Birth / MM / DD YYYY
Student ID Number

Please leave blank, if unknown
Please briefly summarize or list the clinical issues of focus in the student's treatment with you.
Please describe treatment plans you anticipate, both short-term and long-term, including any medication management.
At this time, do you think that a Medical Leave of Absence (MLOA) from Northwestern (typically a duration of two academic quarters) could be beneficial for this student's well-being and recovery?

At this time, do you think that a Medical Leave of Absence (MLOA) from Northwestern (typically a duration of two academic quarters) could be beneficial for this student's well-being and recovery? Yes No
If you answered "no" to the previous question, please elaborate.
Below are typical treatment recommendations providers may give for a student pursuing MLOA. Please check any that you think may be beneficial for the student's well-being and recovery during their MLOA. If you have questions regarding treatment recommendations for a student's MLOA, please call NM Student Health Service: 847-491-8100.

Below are typical treatment recommendations providers may give for a student pursuing MLOA. Please check any that you think may be beneficial for the student's well-being and recovery during their MLOA. If you have questions regarding treatment recommendations for a student's MLOA, please call NM Student Health Service: 847-491-8100. Receive an evaluation at a program offering intensive outpatient or partial hospitalization programs (IOP or PHP) or a residential treatment program. Follow all treatment recommendations including any after-care treatment (this includes medication stabilization) or recommendations through the reinstatement process. Receive a comprehensive evaluation at a licensed substance use treatment facility. Follow all treatment recommendations including any after-care treatment or recommendations through the reinstatement process. Medication initiation and stabilization managed by your provider or program treatment team. Follow all treatment recommendations including any after-care treatment or recommendations through the reinstatement process.
Following completion of a primary treatment program (i.e. inpatient stay, substance abuse treatment program, residential treatment, PHP, IOP), secondary treatment is often needed to sustain progress during the transition back to the academic environment.

Please select from the following secondary treatment options:

Following completion of a primary treatment program (i.e. inpatient stay, substance abuse treatment program, residential treatment, PHP, IOP), secondary treatment is often needed to sustain progress during the transition back to the academic environment.

Please select from the following secondary treatment options: Individual Therapy Individual Psychiatry/Medication Management Group Therapy Intensive Outpatient Program (IOP) Other Other
Provider Information
Treatment Provider's Name Treatment Provider's Name First Last
Treatment Provider's Phone
Treatment Provider's Email
Treatment Provider's Work Address
Treatment Provider's License #
State/Location Where Licensed
Provider's 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.

Healthcare Provider Report Form: Medical Leave of Absence

Healthcare Provider Report Form: Medical Leave of Absence

Student Information

Provider Information