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Counseling and Psychological Services

University Health Services


Princeton University
TREATMENT PROVIDER FORM
Dear Provider: You have been asked to complete this form as part of the process by which students returning from
leaves of absence are transitioned back into the university. We want to ensure that students are safe to return to
campus and that we put in place all that is necessary to help students be successful. Your assessment and
recommendations are an integral part of this process. Please contact the Associate Director of CPS at 609-258-3285 if
you have any questions or concerns. Please mail completed forms to: Counseling and Psychological Services, McCosh
Health Center, Princeton University, Princeton, NJ 08544; or fax to our confidential fax line 609-258-7636.

PART I: TO BE COMPLETED BY STUDENT


Name of student:
Date of withdrawal:
Application to be Readmitted to:
Fall
Undergraduate college/Graduate department:
Providers seen since leave:

Class year:

Spring

Year:

PART II: TO BE COMPLETED BY TREATMENT PROVIDER


Name of provider:
Address:
Telephone:
Email:

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

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