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Mental Health Withdrawal Policies

Below is an itemized list of each document you will need to submit as a part of your Mental Health Withdrawal packet.

Your Responsibilities

You are required to request and ensure that all documentation is submitted in a timely fashion. All documents must be provided or completed within one month of the initial request. If documentation is not submitted within one month, the file will be closed and no further action will be taken regarding the request. If you have any questions and/or need additional guidance completing your Mental Health Withdrawal packet, please contact the UTSA Counseling Services office at (210) 458-4140. The required documentation includes the following:

  1. Authorization To Release Records For Medical/Mental Health Withdrawal Request - This document allows UTSA Counseling Services permission to act on your behalf with Academic Support and Undergraduate Studies, Dean of Graduate Studies, Business Office, the Registrar’s Office, and Financial Aid. Download the Authorization to Release Records Form for Medical/ Mental Health Withdrawals.
  2. Authorization To Release Information For Medical/Mental Health Withdrawal Request - This document enables the UTSA Counseling Services office to contact and/or accept corroborating documentation from your doctor, provider, therapist, etc. for the purpose of your Mental Health Withdrawal. Download the Authorization to Release Information Form for Mental Health Withdrawals.
  3. A signed Counseling Services Informed Consent: Mental Health Withdrawal Requests. This document provides explanations of confidentiality, maintenance of records, services offered, and emergency/after-hours resources. Download the Informed Consent Form.
  4. A typewritten statement by you with an explanation of why you are requesting a mental health withdrawal. Please include the dates of when this problem/concern began. Please be descriptive regarding the severity of your condition (i.e. how your problem affected your ability to complete the semester in question). Download the Student Statement Form.
  5. A statement on letterhead from your attending health care provider (i.e. physician, therapist, psychiatrist, psychologist, etc.) to include dates of onset of problem, diagnosis, plan of treatment, prognosis, and his/her recommendation for withdrawal. You will be required to sign a release so that UTSA clinician/staff can verify this information with your health care provider. If your mental health withdraw request is in regards to a recent death, a copy of the death certificate will be required. Download the Health Provider Statement Form for Mental Health Withdrawals.
  6. A current transcript (i.e. can be an unofficial copy) of your academic record. Transcripts can be requested by accessing the Registrar’s Office website.
  7. Any supporting documentation to verify validity of your concern/problem (e.g. hospital records, police report, emergency department summary, court records, etc.).

Additional Resources

The following forms have been included to provide further information as to UTSA’s policy for Mental Health Withdrawals. You do not need to submit these documents as a part of your Mental Health Withdrawal packet. Please click on the following links as needed to learn more about university policies regarding Mental Health Withdrawals:

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