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Treating Healthcare Professional Questionnaire


This form is to be completed by the treating physician, other M.D., licensed mental health provider, or other qualified health care provider. Please respond to the questions listed below and attach a brief statement concerning whether this student is prepared to resume full-time study and a treatment summary on your office letterhead.

Provider's Information

Please provide the following information about yourself as the provider:

 
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Example: Psychiatrist, MD, Licensed Mental Health Provider, etc.
Email address must be of a valid format.

Student/Patient Information

Please use the following fields to provide information about the student/patient with whom you worked:

Involved party 1

Student/Patient Information Needed from Provider

Please address all of the following questions/issues in the space provided below:

This field is required.
This field is required.
This field is required.
If treatment is continuing, select the type of treatments that are recommended or being utilized:
You must make at least one selection.
This field is required.
Do you believe the student can fully function on a large college campus without accommodations?(Required)
This field is required.
This field is required.
Do you have any concerns for the safety or well-being of the student?(Required)
This field is required.
This field is required.
Are the student's parents/guardians aware of his/her condition and treatment?(Required)
This field is required.
This field is required.
This field is required.
This field is required.

Supporting Documentation

Please attach any supporting documentation here. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission