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MLOA:
Request for a Voluntary Medical Leave of Absence


Approval for a voluntary Medical Leave of Absence is granted by the Dean of Students Office in consideration with a recommendation from either CAPS or Health Services (even if you might also be working with an outside treatment professional). Your request for a leave will generally not be reviewed until you have met with CAPS (and signed release of information with current provider if you have one) OR have been in contact with and submitted necessary documentation and release of information to Health Services. After receiving recommendations from CAPS or Health Services, the Dean's Office will issue a decision regarding the appropriateness for a leave of absence. After submitting this form, please contact either CAPS or Health Service to schedule a medical leave assessment.

General Information

 
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Your Information

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Questions

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Are you currently working with a treatment professional outside of Northwestern (e.g., doctor, therapist, psychiatrist)?(Required)
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If you are an undergraduate student or a financial dependent, have you already spoken to your parents/guardians about your desire to take a Medical Leave of Absence?(Required)
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Students who are granted voluntary Medical Leaves of Absence are generally expected to engage in a course of professional treatment to address the underlying issue(s) that necessitated the leave of absence. Do you understand this?(Required)
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Please check each item that describes you:(Required)
You must make at least one selection.
I have read and agree to the terms and conditions of Voluntary Medical Leave of Absence Procedure and the Reinstatement from Voluntary Medical Leave of Absence Procedure as listed on the Dean of Student's website: http://www.northwestern.edu/studentaffairs/dos/programs-services/medical-leave-of-absence/index.html(Required)
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Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Type of Medical Leave

*REQUIRED* Please select the reason for which you are requesting a medical leave of absence.
*REQUIRED* Please select the reason for which you are requesting a medical leave of absence.

Submission