Healthcare Provider Report Form: Reinstatement

Healthcare Provider Report Form: Reinstatement

Northwestern University students requesting reinstatement from 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 reinstatement should be granted.

Northwestern is a comprehensive research university that is deeply interdisciplinary across multiple schools. Our rigorous, yet empathetic, academic environment is impactful, producing top-tier research, new knowledge, creative expression and practical application. Students returning from medical leave of absence should be able to fully and consistently engage in their academic pursuits. This means students will be responsible for adhering to class attendance policies, completing coursework in accordance with established deadlines, and participating respectfully and collaboratively in all learning environments. All Northwestern students are expected to be self-sufficient, able to live safely and independently, care for their basic human needs, and treat other members of the Northwestern community with dignity and respect.

Treatment Provider: As you are completing this provider report, please keep this in mind and talk to your client about the environment and expectations for engagement. It is important that we have as much information from you as is possible so we can support the patient’s success upon return. You have the option to save your work and resume at a later time.

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

For more information about MLOA and Reinstatement:
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's ID Number

Please leave blank, if unknown.
Current Diagnosis
Primary Treatment Modality During Medical Leave of Absence

Primary Treatment Modality During Medical Leave of Absence Residential Treatment Program Substance Abuse Treatment Program Partial Hospitalization Program (PHP) Intensive Outpatient Program (IOP)

Please check all that apply to your contact with the student.
Primary Treatment Program Name
Primary Treatment Program Facility Address
Date of Program Admission
Date of Program Discharge (please elaborate if the student terminated the program early)
If psychotropic medications were prescribed, did the student adhere to treatment?

If psychotropic medications were prescribed, did the student adhere to treatment? Yes No N/A
Please provide details about the student's progress in the sections below.
Has there been a substantial improvement of the student's original health/psychological condition?

Has there been a substantial improvement of the student's original health/psychological condition? Yes No
Please describe how the student has or has not managed to reduce problematic symptoms and behaviors during treatment and provide details regarding their current level of functioning and stability. Please also include a statement regarding the student's nutrition status, if relevant.
In your professional judgement, given the academic rigor and social challenges of the environment to which the student will return, do you believe the student is healthy enough to continue pursuing their education at the current time?
Please provide details related to ongoing treatment in the sections below.
Since completion of the primary treatment program, what ongoing treatment or outpatient care has the student participated in?

Since completion of the primary treatment program, what ongoing treatment or outpatient care has the student participated in? Individual Therapy Individual Psychiatry/Medication Management Group Therapy Intensive Outpatient Program (IOP)

Please check all that apply to your contact with the student.
Please use the space below to note recommendations for ongoing treatment or outpatient care the student will need upon return to campus.
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
Upload Files. If the patient has been in a hospital, PHP, IOP or residential treatment program, please include initial evaluations and discharge summaries.

Attach Files
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