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
Re-Entry Request
Health Provider Report Form
To Be Completed By Student:
Student Name (Last, First, MI):____________________________________________________
Student ID:__________________ DOB:_________________ Cell #:_________________
Describe in detail your re-entry plan and any special requests you may have to assist you in
successfully continuing with classes at KSU (additional pages can be added or this information
can be emailed to deanofstudents@kennesaw.edu).
I acknowledge that all information provided by me and/or my heath 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. This re-entry form relates to medical/psychological
withdrawal re-entry only and is independent from any readmission requirements that may exist
through KSU Admissions and/or any specific academic program or college.
Student Signature: __________________________________
Date: ________________
(if emailing the form directly from your KSU student email, signature is not necessary)
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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
Re-Entry Request
Health Provider Report Form
Student Name (Last, First, MI):____________________________________________________
Student ID:__________________ DOB:_________________
Today’s Date: ___________
The above named student is applying to return to Kennesaw State University following a medical
leave. Your information will help us determine this student’s readiness to return to school.
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
☐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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Recommendation:
To return to Kennesaw State University a student must be able to function autonomously on
campus. The student should not require supervision or monitoring for safety. The student should
be able to take responsibility for arranging and following through with any further treatment.
If a student’s condition meets the criteria for a disability as defined by the Americans with
Disabilities Act, disAbled Student Support Services can provide appropriate accommodations.
(Contact: Nastassia Sanabria 470-578-6443, nsanabria@kennesaw.edu)
Based on the above criteria is this student ready to return to Kennesaw State University?
☐No
☐Yes
☐Yes, with 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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