Get Community Provider Report Form A Request To Return From Hrloa Marillac Hall, Room 130 8000 Utopia

This guide provides step-by-step instructions for completing the Community Provider Report Form A Request To Return from HRLOA. It is essential for a licensed mental health service provider to fill out this form to assist students in their return to university.

Follow the steps to complete the form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the Community Provider Report Form and open it in your preferred online editor.
2. Begin by entering the clinician's name in the designated field. This identifies who is responsible for completing the form.
3. Fill in the student's name as it appears in their official records to ensure proper identification.
4. Specify the clinician's license type in the designated area, indicating the level of professional qualifications.
5. Record the date of the first session with the student, which serves as a reference point for treatment duration.
6. Provide the clinician's license number to validate their professional status.
7. Enter the date of the most recent session, capturing the latest interaction between the clinician and student.
8. Indicate the state in which the clinician is licensed. This information is crucial for jurisdiction verification.
9. Fill in the total number of treatment sessions conducted with the student, providing a clear picture of treatment history.
10. State the initial DSM Axis I diagnosis to offer insight into the student's original mental health condition.
11. Provide the Global Assessment of Functioning (GAF) score at the first session to convey the baseline functioning level.
12. Specify the current DSM Axis I diagnosis, which helps in understanding the student's present mental health status.
13. Record the current GAF score to assess the present level of functioning.
14. Provide professional judgment on the amelioration of the student’s original medical/mental health condition by answering yes or no.
15. If there has been improvement, check all observed reductions in symptoms and behaviors relevant to the student's condition.
16. Confirm if the improved condition has been maintained for at least three consecutive months by selecting yes or no.
17. Answer the questions regarding safety-related behaviors, indicating if there has been a substantial reduction over time.
18. Finalize the form with the clinician's signature and date at the bottom of the page.
19. On letterhead, provide written documentation elaborating on responses, outlining current diagnosis, treatment targets, and approach.
20. Review the completed form for accuracy, then save changes, and download, print, or share the form as necessary.

Complete the Community Provider Report Form online today to assist in the student's return process.