Physician or Mental Health Professional’s Assessment and Recommendation Regarding Patient’s Need for Academic Relief

 (please write very legibly)
Date:  Student ID#: 
Patient’s Name : DOB:
 
Physician or Mental Health Professional Providing This Report:
Name and Degree: 

 

_____Physician
_____Psychiatrist
_____Psychologist
_____Counselor
_____Social Worker 
_____Other: 
Business Address:

 

 
Phone:
Fax#:
Treatment Information:
Date of patient’s initial appointment with you:
Date of patient’s last appointment with you:
Total number of times patient was seen by you:
(Check all that apply)

Treatment modalities used:

_____ psychotherapy
_____ pharmacotherapy
_____ other,  specify:

 
Description of symptoms at time of first appointment with you:

 

 

 
Prescribed medications and dosages:

 

 
Will patient be continuing with medication tx?   _____ Yes   _____ No  
Issues addressed in treatment with you:

 

 

 
Your diagnosis of patient (DSM IV-TR):
Axis I:
1)
2)
3)
4):
Axis II:
Axis III:
Observed changes in patient’s functioning during time in treatment with you: 

 

 

 
Remaining functional difficulties which need to be addressed in continued treatment:

 

 

 

Check any that may apply:

 

_____ Anxiety Symptoms

_____ Attention / Concentration Impairment

_____ Bipolar Mood Instability

_____ Depressive Symptoms

_____ Eating Disorder

_____ Homicidal Ideation/Intent

_____ Interpersonal Difficulties

_____ Motivational Difficulties

_____ Obsessions/Compulsions

_____ Panic Symptoms

_____ Personality Disorder

_____ Post Traumatic Stress Symptoms

_____ Psychotic Symptoms

_____ Self-Destructive Behavior – Non-Suicidal (i.e. – cutting)

_____ Sleep Disturbance

_____ Social Phobia Symptoms

_____ Substance Abuse/Dependence

_____ Suicidal Ideation/Intent

_____  Other:

If any were selected above, please elaborate, particularly with regard to whether or not student’s remaining functional difficulties may contraindicate a return to the academic environment.

 

 

 

 

 

 

Explain how patient’s symptoms my have affected academic functioning:
Signature of Provider:

 
Date: