Health Care Provider Assessment Form - College of William and Mary

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Office Phone: 757-221-2510 Fax: 757-221-2538

Health Care Provider Assessment Form (Psychological) Student Name: Person providing this assessment: MD (Psychiatrist)

Psychologist

Social Worker

Licensed Counselor

(Circle all that apply)

Other: State of Licensure: Phone Number:

License Number: Fax:

Section A Date of most recent appointment:

Date of initial appointment: Total number of times you have seen the student: Treatment modalities provided: Psychotherapy

Pharmacotherapy

Other: Diagnostic Impressions:

Section B

Prognosis: Current Medications and Dosages:

Updated February 2017

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Please record the symptoms that the student has demonstrated. Circle the appropriate response for each. Symptoms observed when Symptoms addressed by Remaining symptoms which student began medical may periodically impact the treatment provided leave by you academic functioning Yes No N/A Yes No N/A Yes No N/A

Attention & Concentration Difficulties Body Image/Eating Issues Depressive Symptoms Homicidal Ideation/Intent Interpersonal Difficulties Mood Instability Motivational Difficulties Obsessions/Compulsions Panic Symptoms Post Traumatic Symptoms Psychosis Self-Harming (non-suicidal) Sleep Disturbance Social Phobia Substance Abuse/Dependence Suicidal Ideation/Intent Other:

Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A

Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A

Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A

If this request is related to re-entry (Medical Clearance, etc), please continue to Section C. If this request is related to Medical Withdrawal/Leave of Absence, please proceed to Section D. Section C Has the substantial reduction in safety related behaviors been maintained with stability for at least three consecutive months? Yes No N/A Comments:

Does the student appear capable of functioning autonomously and successfully in a rigorous full-time academic environment (4 courses)? Yes No N/A Comments:

Is follow up and/or after care treatment recommended, or reasonable ADA accommodations? If yes, please specify type(s) of recommended treatment: Yes No N/A Comments:

Updated February 2017

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Provide your opinion of student’s readiness for re-entry to William & Mary and provide explanation in the space provided below for comments: Ability to resume full-time academic enrollment and residential living or off-campus living: Academic responsibility often consists of 12-15 credits of rigorous academic course loads, 3-5 extracurricular activities often with leadership responsibilities, and possible athletics and/or research involvement. Residential living is either alone or with roommates/dorm living where student must maintain all activities of daily living without supervision. Off-Campus living will include all activities of daily functioning independently without supervision. Student is ready to resume full-time academic enrollment and residential living if available. Ability to resume full-time academic enrollment but not residential living: Academic responsibilities are outlined above, however, this may mean you do not feel student is able to live within a dorm environment due to interpersonal conflicts connnected with mental health symptoms and/or may require some level of supervision with managing aspects of their treatment plan or daily activities. Student is ready to resume full-time academic enrollment, and is not ready to live in residence. Student is not ready to return to academic enrollment or residential living: Student has demonstrated that they are unable to manage symptoms without significant support in managing continued treatment plan, unable to live independently without regular supervision, and/or have significant interpersonal concerns due to mental health/safety that would be disruptive to the learning and living environments of others until better managed. Student is not yet ready to resume academic enrollment. Comments:

Please include/attach a detailed treatment summary of the issues addressed in therapy as well as this student’s progress.

Section D By signing where indicated below I am representing to the College of William & Mary that my response to each question listed above is true, complete, and accurate to the best of my knowledge and belief, this it constitutes my best professional judgment and opinion, and that the Patient did not prepare or draft that response for my signature. Signature:

Date:

Please attach your business card to this form. Please fax this information to the Dean of Students Office (F: 757-221-2538). If you have any questions please contact the Case Manager at 757-221-2510. Updated February 2017

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Health Care Provider Assessment Form - College of William and Mary

Office Phone: 757-221-2510 Fax: 757-221-2538 Health Care Provider Assessment Form (Psychological) Student Name: Person providing this assessment: MD ...

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