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Health Care Provider Report

Student Instructions: Share the link to this form with each of your treatment providers at your first session (or assessment session). We recommend you also provide a copy of your MLOA recommendations letter from the Dean of Students Office.

Treatment Provider: Please complete this form and submit it electronically. You have the option to save your work and resume at a later time.

Click here for Health Care Provider Report – Medical Leave of Absence

click here for Health Care Provider Report – Reinstatement