Counseling and Psychological Services University Health Services Princeton University QUESTIONS for TREATMENT PROVIDERS, PLEASE NOTE: This form must be received no later thon July 1" fr all follre-admission requests and by January 1" for all spring re-admissions. Re-admission interviews con be scheduled by calling CPS at 609-258-3285. However, interviews will ‘not be scheduled i ths form isnot received by CPS by the date indicated. f there is more than one treatment provider, ‘each provider should complete a separate form. Please mailto: Counseling and Psychological Services, MeCosh Health Center, Princeton University, Princeton, NI O8544; or fax to: our confidential fax lin 609-258-7636. Name of student: lass year: Date of withdrawal: = ‘Application tobe readmitted to Dra C0 Spring Year: Undergraduate college/Graduate department: Reason for leave Provider(s) seen since leave: Please complete and fax with the UHS release of information so that we may speak to your provider(s). ES [Name of provider: Degree: Address: ity: State: Telephone: ip Fax Email: Please note that a CPS clinician may contact you for further information regarding the student's treatment, if needed. A. Treatment Provided During Leave 1. Date and type of treatment provided: (please check all that apply) ‘Initial appointment Lastappointment/ — # of sessions / Dateof Admission Date of Discharge Length of stay 1 inpatient Treatment 1 Intensive Outpatient Treatment 1 outpatient therapy regular) 1 Outpatient Pharmacotherapy C1 Specialized Treatment (eg. Eating Concerns, Alcohol and Other Drugs Counseling, etc)“Medications prescribed: ‘Name Dosage | Dateinitiated | Date ofCurrent | Date Discontinued Prescription Focus and type of treatment (please describe targets for treatment, include modality used, goals of treatment, ‘Towhat extent was the student compliant with treatment? (e.g, attended sessions regulary, ook medications as prescribed, etc). Please explain fully B. Presenting Concerns and Changes L What were the primary concerns atthe time the student first sought treatment with you? ‘To what extent was the treatment effective to address the issues, concerns, and circumstances related to the student's withdrawal from school? Please provide your diagnostic assessment, using both the DSM-IV TR diagnosis and your diagnostic impressions. OSMIVTR Beginning of treatment CCurrent/at discharge date xis | xis ‘xis axis pais V Other diagnostic impressions:4, Has the student’ functioning now or at any time been compromised by any of the following? Please describe briefty ll that apply. o a a o a a In the past (specify time peri rent (specify time peri ‘Alcohol or drug abuse Eating disordered behaviors Psychotic symptoms ‘Suicidal statements, attempts, oF gestures Non suicidal self harm behaviors ‘Agitation or disruptive behaviors ‘that affected others Bipolar instability 'Neuro-vegetative mood symptoms ‘Attention/Concentration problems Motivational problems. Interpersonal difficulties Severe anxiety Obsessions or compulsions Doogooo ‘any of the above were selected, please elaborate with particular reference to any progress thatthe student has ‘made in treatment in addressing these issues. . Readiness to Return to Schoo! 1 Please give us your assessment ofthe student's readiness to return to Princeton, LF No reservation regarding student's readiness to return Some reservations regarding student’s readiness to return D student is not ready to return Please explain, with supporting data (.9. period of remission of symptoms and stability, evidence of enhanced functioning, coping sil insight, et). 2._ Please give us your assessment of any remaining functional difficulties or impairments that exist. 3. Would these contraindicate or make more dificult a return toa high-stress academic environment?4. Please comment on ‘Student's ability to manage stress ‘Student's level of insight into problem. Students coping skils developed Resiliency “Triggers to be monitored '._ Please provide your clinical recommendations to enhance the student's capacity for success subsequent to readmission to Princeton Universit. Please tell us f continuing treatment is recommended upon return to school. (Be sure to speciy the type, frequency and duration of care you feel is necessary, andthe symptoms or functional difculties that on-going treatment will need to address.) 6. What would you estimate tobe the risk of relapse if this treatment were not available or accessed by the student? Please explain Signature of Treatment Date ‘Name and Degree of Treatment Provider ‘Agency/Organization ‘Thank you for completing this form. Please feel free to attach any relevant documents/notes. Please mail to: Administrative Evaluations Coordinator, Counseling and Psychological Services, McCosh Health Center, Princeton University, Princeton, NJ 8544; or fax to: our confidential fax line 609-258-7636,