The following forms may be needed when seeking support through Student Health and Counseling:
Please fill out the request form in its entirety, including the special records section and chose one way to have them sent to you. If a form is not completely filled out, we will need to contact you which may delay the processing of your request. Please allow two weeks for records to be sent.
If you have taken a Leave of Absence as a result of a medical condition and are ready to return to academics, please fill out this form and have your medical provider(s) complete and sign the form. The medical provider(s) must be the clinicians who are currently treating you for the condition.
All requests to return from a leave of absence begin with your academic advisor. After you make contact with your advisor, you may be directed to a counselor with Student Health and Counseling as part of the return from leave process. If you require our involvement in this process, please fill out the form and work with your provider to submit.
Please complete this form so that Student Health and Counseling may share information about your counseling treatment with a designated individual (for example, an advisor, your parents, or a coach).
Forms for PSIP (Penn Student Insurance Plan)
- Aetna Claim Form
- Aetna Prescription Drug Claim Form
- Aetna Prescription Home Delivery Order Form (English)
- Aetna Prescription Home Delivery Order Form (Spanish)
Visit the Immunization Requirements page for current forms and submission instructions.