Student Health Support Plan Template

(to be completed collaboratively by student and Dean of Students or other Calvin staff member at the time of return from Health Leave)

This form will be accessible by Calvin staff involved in the Health Leave process upon submission, with information shared between staff members only on a need-to-know basis. Questions about the confidentiality of the form can be directed to the Dean of Students office (deanofstudents@calvin.edu).

Student information

First Name

Last Name

ID Number

Email Address

Date

Completed with (staff name):

The academic and social environment of university can be rigorous, and Calvin’s goal is to support students in the safe and successful completion of their studies. This Health Support Plan serves as an initial guide as you maintain your health, both physically and mentally, during your time at Calvin University. You can use the following questions to help shape your plans for successful management of your health via 1) treatment planning, 2) identification of health-related goals & resources, 3) commitment management, and 4) other requirements.

Questions

Treatment plans

How will you incorporate any needed treatment into your life as a student?
Ex. What medical and/or mental health treatment has been recommended by your health care providers? Where, when, how, and with whom will you follow those recommendations during your time at Calvin?

Health-related goals and resources

How will you incorporate wellness activities into your life as a student?
Ex. What routines and habits will support your wellness (ex. exercise, sleep, eating, social connection, faith practices, time management, hobbies, etc)? Which people and resources will support you in carrying out these healthy activities?

Commitment management

How will you determine the amount and type of commitments that work best in your life as a student?
Ex. What quantity and type of for-credit classes will best support your wellness? Will employment and/or volunteer work help or hinder your wellness as you juggle the multiple demands of the university environment?

Other requirements

Are there specific requirements you have been asked to fulfill in order to return to Calvin?
Ex. Have any other requirements been laid out for you for your continued enrollment (ex. conduct, academic, etc)? If so, how will you go about meeting those expectations and who will be your primary supports and contacts in the process?

Dept Email

Record ID

Age

Contact Information