STUDENT MEDICAL LEAVE LETTER

[Practice name]
[Address]
[Phone and email]

Date: [Date you write the letter]
To: [Dean of students, registrar, or the office named in the school's instructions]

Re: [Student's full name]
Date of birth: [Date]
Student number and program: [If the student gave them; otherwise delete this line]

This letter is for: [A leave of absence, using Part 1, or a return from leave, using Part 2. Delete the other part]

PART 1: LEAVE OF ABSENCE

I assessed [student name] [in person, by video, or by phone] on [date of the visit]. I have treated them for this since [date, or this was the first visit].

In my opinion, their health currently prevents them from [studying, or attending classes, or completing this term's work and exams].
What they can't manage at present: [Effects on study, e.g. can't concentrate through a lecture, can't keep a regular routine, missed most classes since a date]
Leave recommended from: [First day of the leave]
Expected length: [The rest of this term, 1 term, 2 terms, or to a date]
I will reassess on: [Date]
Reduced course load: [Considered and not enough at present, or recommended instead of a full leave, with how many courses]
Treatment plan: [With the student's consent: the care in place in general terms, e.g. weekly therapy and visits with me every 2 weeks. Without it: A treatment plan is in place]

PART 2: READINESS TO RETURN

Care during the leave: I have treated [student name] from [first date] to [last date], [number of visits, and any program they completed]. I last assessed them on [date].
Term they are applying to return for: [Term and year]

In my opinion, they are [ready, ready with the supports below, or not yet ready] to return [full-time, or with a reduced course load] from [first day of term].
What has improved: [Daily function now, e.g. regular sleep and meals, keeping appointments, part-time work or volunteering]
Concerns: [None, or what concerns me and what would help]
Care that continues: [Treatment, how often, and who provides it during the term]
Course load for the first term: [Full load, or the number of courses I recommend, and when to review it]
Accommodations: [None, or what I recommend, for the school's accessibility office to arrange]
I will review the plan on: [Date, e.g. mid-term]

The school's form: [If the school sent its own form or questions, I have answered them there; otherwise delete this line]

Diagnosis: [Not included, or with the student's consent: the diagnosis or a plain description they agree to]

[Student name] asked me for this letter and agreed to what it shares and who receives it.

[Your name, credentials]
[License or registration number]
[Signature]

To confirm this letter came from me: [Practice phone]