Student Provider Health Leave Request

Provider instructions: A Health Leave of Absence from Calvin University is under consideration for this student in order to address personal health concerns. Students who take a Health Leave are encouraged to use time away to focus on treatment and recovery, creating a specific Health Leave Plan in collaboration with Calvin personnel at the commencement of their leave.

Your input here will support the Dean of Students (or other Calvin personnel) in determining whether a Health Leave is advisable for this student and also what conditions might indicate that the student is healthy enough to return to the rigorous academic and social environment of university in the future. You are welcome to attach additional documentation to expand on your comments regarding the student’s ability to function safely and successfully.

Due to the time-sensitive nature of the Health Leave decision, it is requested that this provider form be submitted within three business days of receipt. Information can be submitted to the Dean of Students at Calvin University using the online form below. Alternatively, you may choose to print a PDF version and submit it via one of the following methods:

email attachment – deanofstudents@calvin.edu
fax – 616-469-2979 (c/o Director, Center for Counseling and Wellness)
in-person – Dean of Students, Student Life Office (Spoelhof Center 364), Calvin University, 3201 Burton St SE, Grand Rapids, MI 49546

The full Health Leave of Absence Policy for Calvin University. Thank you for your time!

Student Information

First Name

Last Name

Date of Birth

Phone Number

Provider Information

Name & Degree/Credentials

Practice/Organization Name

Phone Number

Email Address

Fax Number

Mailing Address

Questions

Reason for Leave: Please summarize the student's reason for treatment.

Please describe the specific date(s) and type(s) of treatment provided, including any known ER visits or hospitalizations.

Please provide a brief description of how this student's health issues have impacted academic and/or social functioning in the university environment.

Goals for Leave: Please provide a brief description of how a Health Leave of Absence from the university may or may not be helpful for this student. Is it anticipated that a Health Leave might improve the student's health and contribute to their successful return to Calvin University?

Activities During Leave: What are your specific treatment recommendations for this student to address current health concerns?

Do you have additional recommendations for this student's time on Health Leave (work, education, housing, activities, etc...)?

Any additional notes or considerations for the university to take into account, as related to Health Leave for this student and safe return to the university environment in the future?

Additional Notes or Relevant Documentation

Signature

Dept Email

Record ID

Contact Information