MLOA: Request for Reinstatement from a Medical Leave of Absence

General Information

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First Letter of Your Last Name(Required):

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Today's date(Required):

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School of Enrollment(Required):

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Select PRIMARY school if enrolled in more than one

Specific Program/Field:

Your Information

Your Full Name

Your NUID Number

Your DOB (YYYY-MM-DD)

Your Cell Phone Number

Your NU Email Address

Your CURRENT Address

Additional Questions

Desired quarter to return:(Required) This field is required.

What is your current class standing?(Required) This field is required.

What is your PERMANENT home address?(Required) This field is required.

What is current CELL phone number?(Required) This field is required.

What is an ALTERNATE (non-Northwestern) email address for you?(Required) This field is required.

Please describe your activities, employment, studies, and most importantly treatment and service since you left the university, and please also explain what you have learned from those experiences.(Required) This field is required.

Please explain why you believe you are ready to return to the University at this time. What have you learned through the process of medical leave about managing your health or mental health while at Northwestern?(Required) This field is required.

Provider report forms

If you took a medical leave for mental health reasons, at the time of your request for reinstatement, please submit your provider report form(s) and release(s) of information for each of your treatment providers as well as the dean of students office. The provider report form can be found in your original medical leave letter. You can also find both the provider report form and the release of information on the CAPS website, where there is also a reinstatement from medical leave portal to guide you through each step. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Reinstatement Request

*REQUIRED* Please select the office with which the Dean of Students Office will be communicating regarding your request.

CAPS (GG, CC, CA, SBC, AA, KT, LM, JG)

UHS: University Health Services (KA, LM, CN, JH)

General Information

Your Information

Additional Questions

Provider report forms

Reinstatement Request

Submission