Attachment IV
TREATING DOCTOR’S RE-ENROLLMENT QUESTIONNAIRE
Instructions: This form is to be completed by the treating psychiatrist or licensed psychologist. Please respond to the questions listed below and attach a brief statement of recommendation for re-enrollment and a treatment summary on your office letterhead. Send the completed form and statement directly to the following address:
Office of the Dean of Students
Texas State University-San Marcos
Full name of patient: ___________________________________________________________
Are you a: ____Psychiatrist ____Licensed Psychologist?
Did you provide treatment for the above-named patient? ____Yes ____No
How many treatment sessions have you provided for the patient (relating to this matter)?
Treatment has consisted primarily of: __medication management __psychotherapy __both
Has the above patient completed treatment? ____Yes ____No
Are you continuing to provide treatment? ____Yes ____No
If not, was treatment terminated with your approval? ____Yes ____No
When did the treatment commence? __________________ Conclude? ________________
If the patient has not
completed treatment, how frequently will the patient need to see you?
____________________________________________________________________________
Have you referred the patient for continuing treatment? ____Yes ____No
If yes, please indicate the name, address, and phone number
of the individual or agency:
____________________________________________________________________________
Why have you referred the patient for continuing
treatment?
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
If the patient is continuing treatment with you or someone
else, do you believe he or she would be able to function appropriately as a
student at this University without the continued treatment?
____Yes ____No
Do you consider that the patient presently, or in the
reasonably foreseeable future, is likely to be a danger to himself or herself
or others, or a threat to his or her own life or the lives of others?
____Yes ____No
If yes, please explain: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Do you think this patient is capable of carrying a full academic load (12 to 18 credit hours) at this University? ____Yes ____No
To your knowledge, are the parents or legal guardians of the patient aware of the problems for which you have provided treatment? ____Yes ____No
Other comments: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________ __________________
Signature of Treating Professional Date
_____________________________________ __________________
Name of Treating Professional Phone Number
(Please print or type)
___________________________________________________________________________
Address of Treating Professional
Please remember to attach a brief
statement of recommendation for re-enrollment on your office letterhead and a
treatment summary. Return to: Office
of the Dean of Students, Texas State University-San Marcos,