SHAC: Forms

Please contact us at (914)323-7277 or email shac@mville.edu for an explanation of our forms or if you have questions about how to complete a form.

Health Forms

• Consent Form for Treatment of Minors at SHAC

• Exemption to Immunization Requirements Application

• Medical Leave of Absence Application

• Medical Leave of Absence Policy

• Provider Evaluation after Medical Leave of Absence

Counseling Forms

• Consent to Obtain Protected Health Information

• Consent to Release Protected Health Information

• Medical Leave of Absence Application

• Medical Leave of Absence Policy

• Policy for Treatment of Minors

• Treatment of Minors in Counseling (Consent Form)

• Provider Evaluation after Medical Leave of Absence

• Request to be a Referral to SHAC

• Student Health and Counseling Acknowledgement