Professional Documents
Culture Documents
Class year:
Spring
Year:
Degree:
City:
Fax:
State:
1. Please describe the date(s) (i.e., beginning and end of treatment, and frequency) and type(s) of treatment
provided (include any medications prescribed, if appropriate):
2. Do you have any concerns about the students psychological state as it pertains to their safety or capacity for
self-care, or the safety of others in returning to Princeton University?
No concerns regarding safety risks associated with the student
Some concerns regarding safety risks associated with the student
Student is not safe to return to Princeton
If you have indicated concerns about safety, or do not feel the student is safe to return, please explain below:
3. Please provide your clinical recommendations for treatment to enhance the students capacity for success upon
his or her return to Princeton University. Please tell us if continuing treatment is recommended upon return to
school. (Be sure to specify the type, frequency and duration of care you feel is necessary, and the symptoms or
functional difficulties that on-going treatment will need to address.)
______________________________________
Signature of Treatment Provider
______________________________
Date
______________________________________
Name and Degree of Treatment Provider
______________________________
Agency/Organization