Request for a Voluntary Health Withdrawal
University of Nevada, Las Vegas
UNLV students may apply for a Voluntary Health Withdrawal (a separation of the student from
the university) if they experience medical or psychological conditions that significantly impair
their ability to function successfully and safely in their role as a student. It is expected that the
time a student takes away from the University will be used for treatment and recovery. A student
must be currently enrolled to be eligible for a Voluntary Health Withdrawal. All paperwork for a
Voluntary Health Withdrawal must be received one week prior to the official Instruction Ends
date on the Academic Calendar for consideration.
Students are required to submit appropriate documentation from a licensed health/mental health
provider to the Health Withdrawal Committee. Students may receive a medical or psychological
evaluation from either the Student Health Center or Student Counseling and Psychological
Services free of charge. A Release of Information will be required to share Protected Health
Information with the Health Withdrawal Committee. The Health Withdrawal Committee will
maintain the confidentiality of all Protected Health Information received from students. The
Health Withdrawal Committee will review your documentation and submit a recommendation to
the Vice President for Student Affairs for final approval.
If granted, a notation of “Health Withdrawal” will appear on the student’s transcript for all
classes taken during the semester the Voluntary Health Withdrawal is approved. An
administrative hold will be placed on the student’s academic record to ensure compliance with
withdrawal agreements and to prevent any unauthorized reenrollment by the student. It should be
understood that most students require a minimum of one semester leave of absence from UNLV
in order to receive treatment and gain stability before returning to UNLV.
A student granted a Voluntary Health Withdrawal will receive a refund of his/her tuition in
accordance with applicable University policies and procedures. If the student is living in the
residence halls, his/her contract will be voided and a refund shall be issued based on the per diem
rate for the unused portion of the semester. The amount of the refund shall be determined as of
the date the student removes all belongings, surrenders the room key, and officially checks out of
the assigned residence hall.
A student who received financial aid during his or her semester of withdrawal should meet with a
financial aid counselor. Unearned portions of financial aid received may need to be returned to
the Cashiering and Student Accounts Office according to U.S. Department of Education
regulations. Financial aid counselors can also discuss any other financial aid eligibility issues
based upon the medical withdrawal.
It is important to understand that students will be required to meet the following conditions of
return before he/she can pursue reenrollment at UNLV:
1. A substantial improvement of the medical and/or psychologica1 condition or symptoms
that precipitated the need for a Health Withdrawal.
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2. The ability to function safely, as evidenced by a substantial reduction of any relevant
welfare-related behaviors, including, but not limited to suicidal behaviors, self injury
behaviors, substance abuse, purging or other potentially harmful compensatory behaviors
used for weight management, or failure to maintain weight at a minimum of 90% of
normal body weight for age and height.
3. The Health Withdrawal Committee must receive the written request to return to UNLV
and submit all required documentation by April 1 for a proposed summer semester
return, July 1 for a proposed fall semester return, and November 1 for a proposed spring
semester return. If you miss one of these deadlines, your return from a Health
Withdrawal may be delayed.
After receiving satisfactory documentation from a licensed medical/mental health provider, the
UNLV Health Withdrawal Committee will review the materials and make a recommendation as
to whether the conditions of return have been satisfactorily met. The Health Withdrawal
Committee may involve an evaluation with a Student Wellness clinician, and if relevant, other
medical or psychological providers.
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Student Checklist for Requesting a Health Withdrawal
1. Complete the following steps before submitting a request for a Voluntary Health
Withdrawal:
 Contact the Advising Office of your particular college/school or your graduate
coordinator to find out what specific academic conditions or restrictions will apply to
you in conjunction with a Voluntary Health Withdrawal, if granted.
 Contact Financial Aid and Scholarships Office at (702) 895-3424 to discuss how a
withdrawal may affect your financial aid eligibility.
 If you are an international student (F-1 visa), you must tell an Office of International
Students and Scholars (OISS) advisor that you are applying to withdraw for the
semester. Contact OISS in SSC-A 311 or call (702) 895-0143.
 Student athletes should contact the NCAA Compliance & Student Services Office
(702) 895-1314 to find out what specific conditions or restrictions will apply to you in
conjunction with a Health Withdrawal, if granted.
 If applicable, contact Campus Housing (702) 895-3489 to find out what specific
conditions or restrictions will apply to you in conjunction with a Health Withdrawal,
if granted.
 Contact your health insurance carrier to determine how a Voluntary Health
Withdrawal will impact your insurance coverage. Students on the UNLV Insurance
Plan should contact Associated Insurance Plans International at (800) 452-5772.
 Contact Dr. Jamie Davidson at (702) 895-0136 if you have any questions about the
Voluntary Health Withdrawal process.
2. Complete the following steps to request a Voluntary Health Withdrawal:
a. Read and sign the Request for a Voluntary Health Withdrawal form. Please include a
copy of part one of the Student Checklist that shows the offices you have contacted.
b. Send the Voluntary Health Withdrawal Provider Evaluation form to your current
provider(s) to document reasons to support your health withdrawal request. Include a
signed Authorization for Release of Protected Health Information form to allow
communication between your current provider and the Health Withdrawal
Committee.
c. Submit all completed paperwork to: Dr. Jamie Davidson, Chair
UNLV Health Withdrawal Committee
4505 S. Maryland Parkway, Box 452005
Las Vegas, NV 89154-2005
Phone (702) 895-0136
Fax (702) 895-4316
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Revised (3/11)
Request for a Voluntary Health Withdrawal
I have read the information above and have asked for any needed clarification and explanation. I
understand the required conditions of return and the deadlines involved in returning from a
Voluntary Health Withdrawal. I accept these conditions and deadlines as part of my
responsibilities in taking a Voluntary Health Withdrawal from UNLV. I agree to abide by these
conditions, and I voluntarily request that the Health Withdrawal Committee issue a
recommendation that I be granted a withdrawal for health reasons. I understand that my signing
this form does not guarantee that I will receive a Voluntary Health Withdrawal.
Reason for requesting a Voluntary Health Withdrawal (be specific as possible):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
I prefer any correspondence about this
leave to be sent to me at the following
address:
Signature of Applicant
Name of Applicant
Student’s NSHE or L#
Date _______________________________
Name of major
Phone number where we may call and
leave a message for you.
Are you registered with ISS?
____ Yes ____ No
Are you an NCAA Athlete?
____ Yes ____ No
Do you live in the residence halls?
____ Yes ____ No
_________________________________
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Health Care Provider Evaluation Summary for Health Withdrawal
To be completed by the student:
Student’s Name: _______________________________
Student’s Date of Birth: ________________
Student’s NSHE or L #: _________________________
Today’s Date: _____________________
To be completed by the health care provider:
Describe the student’s condition and check all boxes that apply:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Recent Safety Related Behaviors
____Suicidal ideation with lethality or imminence
____Suicidal gesture or attempt
____Self-injury behaviors
____Failure to maintain minimum body weight
____Otherwise unsafe to remain on campus
____Disruptive to campus community
____Failure to engage in essential self-care activities
____Other _________________________________
Recent Disruptive Life Circumstances
____Physical or Sexual assault
____Family problems
____Financial problems
____Legal/Office of Student Conduct issues
____Other _________________________________
Recent Functional Impairment
____Marked academic impairment
____Frequent missed classes
____Inability to complete Activities of Daily Living
____Other _________________________________
Existing Treatment Situation
____Failure to respond adequately to current treatment efforts
____Recent hospitalization
____Need for hospitalization or other inpatient treatment at this time
____Other __________________________________________________________________________________________
Brief history of symptoms/condition: ___________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
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Diagnoses: __________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Treatment history: ___________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Describe the reason(s) why the student’s condition warrants a health withdrawal:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Treatment recommendations during the period of the health withdrawal:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________
Provider Signature
___________________________________
Date
___________________________________
Provider Name and Credentials
___________________________________
___________________________________
___________________________________
Address
___________________________________
Telephone Number
___________________________________
Fax Number
This completed form and a Release of Information should be sent to:
Dr. Jamie Davidson, Chair
UNLV Health Withdrawal Committee
4505 S. Maryland Parkway, Box 452005
Las Vegas, NV 89154-2005
Phone (702) 895-0136
Fax (702) 895-4316
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Revised (3/11)
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
I, _____________________________________________________________, authorize the following agencies or persons:
(Student Name)
Agency / Person where information is released from:
Agency / Person where information is released to:
_____________________________________________
(Agency/Person Name, Title, and Organization)
UNLV Health Withdrawal Committee
c/o Dr. Jamie Davidson, Chair
University of Nevada Las Vegas
4505 S. Maryland Parkway, Box 452005
Las Vegas, Nevada 89154-2005
Phone (702) 895-0136
Fax (702) 895-4316
_____________________________________________
(Address)
_____________________________________________
(City, State, Zip)
____________________________________________
(Phone and Fax)
I authorize the release of the following information: All related medical and psychological information.
For the purpose of: Providing documentation for a Voluntary Health Withdrawal from UNLV.
This release is effective on ________________________ and expires one year from this date.
(Signature date)
I understand that I may revoke this consent at any time by giving written notice to the person or organization making the
disclosure.
Witness: _________________________________________
Signed: _________________________________________
(Student Signature)
_______________________________________________
(Student NSHE or L #)
_______________________________________________
(Street Address)
_______________________________________________
(City, State, Zip)
_______________________________________________
(Telephone)
Notice: This information has been disclosed from records that are confidential. Any further disclosure
without the specific written consent of the person to whom it pertains exceeds the limit of this
release.
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Revised (3/11)
Student Checklist for Returning from a Voluntary Health Withdrawal
 Notify the UNLV Health Withdrawal Committee in writing that you wish to
return to UNLV from your Health Withdrawal:
o No later than April 1 for a proposed summer semester return
o No later than July 1 for a proposed fall semester return.
o No later than November 1 for a proposed spring semester return.
 Send each medical/mental health provider you have seen during your time away a
copy of the UNLV Medical /Mental Health Clearance Form. Ask them to
complete the form and mail it themselves directly to the UNLV Health
Withdrawal Committee.
 Mail or fax to the UNLV Health Withdrawal Committee one original copy of the
authorization for releasing, discussing, or obtaining protected health information
from your medical/mental health provider to the UNLV Health Withdrawal
Committee.
 Contact the academic advising office for your college or school, Admissions, and
Financial Aid to notify them of your intent to pursue reenrollment. Begin any
academic planning you may need to do with them. Be sure to ask specifically
what your college requires from you in order to return (e.g., documentation of
activities while away).
 Undergraduate students should complete the Undergraduate Returning Student
Form and return it to the Office of the Registrar and Admissions.
If your documentation is not received by the deadlines specified above,
consideration of your application to return from a Health Withdraw may be
postponed until a later semester. Please note that documentation is reviewed as
it is received; therefore it is to your benefit to submit your materials as early as
possible to speed up the process of your return.
Please send all correspondence to:
Dr. Jamie Davidson, Chair
UNLV Health Withdrawal Committee
University of Nevada, Las Vegas
4505 S. Maryland Parkway, Box 452005
Las Vegas, NV 89154-2005
Phone (702) 895-0136
Fax (702) 895-4316
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Revised (3/11)