Certificate Of Mailing For The Petition For Appointment Of Guardians

6. What is the current treatment plan (include follow-up psychotherapy and medication management,

if any)?

_________________________________________________________________________________________

7. Given the student’s current level of functioning and the treatment plan:

a. What difficulties do you anticipate for the student in performing academically, fitting in within the

university community, or having a recurrence of symptoms?

_________________________________________________________________________________________

b. Is this student able to return to school? If so, do you recommend full-time or part-time status?

_________________________________________________________________________________________

c. Is this student appropriate to live in a university residence? ___________________________________

_________________________________________________________________________________________

8. Please include any additional information:

_________________________________________________________________________________________

Name: __________________________________________________________________________________

Professional Degree: _____________________________________________________________________

Licensure/Certification: ___________________________________________________________________

Address: ________________________________________________ Telephone: ____________________

Signature: ______________________________________________________________________________

_________________________________________________________________________________________

Student’s signature providing release of information

Date

Return to:

NYU Student Health Center • Counseling and Wellness Services

726 Broadway, Suite 471, New York, NY 10003

Or fax to 212-995-4096

Certification of Readiness to Return to School from Medical Leave of Absence - Page 2

Certificate Of Mailing For The Petition For Appointment Of Guardians - New York University Page 3