The Center for Reintegration

Back to Work, Back to Life

Physician/ Prescribing Authority Recommendation

This Recommendation Form must be completed by the applicant’s psychiatrist or prescribing authority (family members cannot fill out forms).

Applicant's Name *
Applicant's Name
Name of the individual for whom you are providing a recommendation
Do you have a HIPAA authorization form on file for the applicant which permits you to discuss his/her health information? *
If a HIPAA authorization form is not on file, this application will be ruled incomplete.
How Well do You Know the Applicant *
Is the applicant’s scholastic record, as you know it, an accurate index of his/her scholastic potential? *
In your opinion, the applicant has: *
In your opinion, the applicant has:
Intellectual Ability
The Ability to Work Independently
Strong Writing Skills
Conceptual Ability
Strong Work Ethic
Sound Judgement
The Capacity to Handle Stress
A Deep Commitment to Recovery
The Determination to Achieve Educational and Vocational Goals
Overall recommendation: *