Kennesaw State University Office of the Dean of Student Success 1000 Chastain Rd. MD 0106, Kennesaw, GA 30144 (phone) 470-578-6310, (fax) 470-578-9113 Email: deanofstudents@kennesaw.edu Medical/Psychological Withdrawal Request Health Provider Report Form To Be Completed By Student: Student Name (Last, First, MI):____________________________________________________ Student ID:__________________ DOB:_________________ Cell #:_________________ Last Date You Attended Your KSU Classes: ___________________________________ (if you are still attending any classes, indicate which classes) Are you seeking to withdraw from all currently enrolled classes? ____ YES If No, please explain why: ____ NO Describe in detail the reasons you are seeking to withdraw (additional pages can be added or this information can be emailed to deanofstudents@kennesaw.edu). I acknowledge that all medical/psychological information provided by me and/or my health provider at my request becomes part of my confidential student record and is protected by FERPA, but is not subject to HIPAA. This information will only be shared with the parties authorized by the Dean of Student Success as part of the review team process. Student Signature: __________________________________ Date: ________________ (if emailing the form directly from your KSU student email, signature is not necessary) If the student is unable to complete this form, please indicate who is submitting it on the student’s behalf and why the student is unable to submit the form personally: Name: ____________________________________ Contact #: _____________________ Address: __________________________________ Email: ________________________ Relationship to Student: _________________________________ Signature: _________________________________ Date: ________________ 1 Kennesaw State University Office of the Dean of Student Success 1000 Chastain Rd. MD 0106, Kennesaw, GA 30144 (phone) 470-578-6310, (fax) 470-578-9113 Email: deanofstudents@kennesaw.edu Medical/Psychological Withdrawal Request Health Provider Report Form Student Name (Last, First, MI):____________________________________________________ Student ID:__________________ DOB:_________________ Today’s Date: ___________ The above named student is applying for a withdrawal from Kennesaw State University for medical/psychological reasons and requests that you provide information to help us determine if this student’s circumstances caused significant impairment in academic functioning that would warrant such a withdrawal. Please complete and return this form via email or fax. If more space is needed in the narrative sections please add additional pages. This information will become part of the student’s confidential student record as protected by FERPA. To Be Completed By Health Provider ONLY: Reason for Treatment: (Check all that apply) ☐Psychiatric☐ Substance abuse ☐Medical Diagnoses: (Use current DSM diagnoses for psychiatric problems) Treatment Modalities: (Check all that apply) ☐Individual Psychotherapy ☐Group Therapy ☐Medication ☐Pain Management ☐Bed Rest ☐Physical Therapy ☐Nutritional Therapy ☐Detoxification ☐ Surgery ☐Partial Hospitalization (List Dates)__________________________________________ ☐Inpatient (List dates) _____________________________________________________ ☐Other (Please Describe)___________________________________________________ ______________________________________________________________________________ Treatment History: Date first seen__________________________________________________________________ Total number of appointments_____________________________________________________ Date of most recent appointment___________________________________________________ 2 Medications: (please include dosage) Labs: ☐N/A ☐Normal ☐Abnormal (please describe) Substance Use/Abuse: ☐Active☐ N/A ☐In Remission (how long?) ( ) 0-1 months ( ) 1-3 months ( ) 3-6 months ( ) 6-12 months ( ) more than 12 months Treatment concerns during your care of this student: (please check all that apply and then provide explanation below) ☐Suicidal threats or behavior ☐Self injurious behavior ☐Violent behavior ☐Homicidal threats or behavior ☐Reckless/high risk behaviors ☐Medical instability ☐Psychosis/Severe Cognitive Impairment ☐Body weight less than 90% of expected ( ) Low weight continues ( ) Normal weight as of (approximate date):____________________________________ Explanation of checked areas: Current Treatment Plan: Discharge/Continuing Care Plan: For Psychiatric illness: Please provide a brief summary of presenting problem and course of treatment: 3 Based on your assessment, does this student’s current medical/psychological condition prevent him or her from being able to perform the behaviors necessary for participation in a college education at this time? ☐Yes Please list the functional impairments: ☐No ☐No, but will need accommodations (please describe) Provider Name_______________________________________Profession__________________ Address____________________________________________ License No._________________ ___________________________________________________Phone______________________ ___________________________________________________Fax________________________ Signature________________________________________________________Date__________ What is the best way to contact you if we need additional information? If student is receiving treatment from other providers, please indicate: Provider Name___________________________________Phone_________________________ Provider Name___________________________________Phone_________________________ Please attach any relevant information that would help us make a decision. Thank you for your help and for taking the time to fill out this form. Preferred submission method is email to deanofstudents@kennesaw.edu with form and documents attached as pdf. 4