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: ________________
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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___________________________________________________
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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:
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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.
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