Clinical Student Site Withdrawal Form

This form is intended to provide National University with your plan to resign from a clinical site.

Please fill this form out to the best of your ability. If you have questions, please email MFTTraining@nu.edu
Today's Date:*

MonthDayYear
Date
Student Name:*

First NameLast Name
Student Email:*
example@example.com
State Seeking Licensure In*
Site Name:*
Site Location:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who sent you this form to complete?*
Clinical Faculty Name*
Clinical Faculty Email
Academic and Finance Advisor Name:*
Academic and Finance Advisor Email
Reason(s) for leaving your clinical site (multiple selections are allowed if applicable):*

Not accruing enough hoursConcerns with Local Site or SupervisorPersonal Issue: i.e., medical, family, or financial matterMoving out of StateWithdrawing from clinical courseWithdrawing from National UniversityOther
Do you already have another site/supervisor?*

YesNo
Please select your current course:*
If you selected "No" to the above, please provide us with your plan to acquire a new site/supervisor. Please acknowledge that you will/have discussed your break/LOA options with your Academic and Finance Advisor as applicable:*
Please provide what week you are currently in:*
If you plan on withdrawing from your clinical course, please provide your plan for either taking a break or Leave of Absence. Please also ensure you are including your Academic and Finance Advisor to this plan:*
Please provide what hours you currently have and where you are deficient:*
If you wish to provide more information related to your personal matter, please do so below:
I plan on moving to the state of blanks* . I will be moving on blank* date.
Please provide the concerns you faced with either local site or Local Supervisor below:*
If you plan on withdrawing from the university, please provide a reason below. Please share this information with your Academic and Finance Advisor; as well as connecting with our Program Director:*

Authorized Site Representative*

First NameLast Name
Authorized Site Representative Email:*
example@example.com
Local Supervisor*

First NameLast Name
Local Supervisor Email:*
example@example.com
Students are able to leave sites, but they generally need to provide a month’s notice to their site. Please provide us with the responses below to the following, in order to ethically exit your site:

**A copy of the below responses will be sent to your site and local supervisor.
The end date of clinical internship at the site:*

MonthDayYear
Date
Do you plan on returning to your site in the future?

NoYes, I am taking a leave and will return at a later date
If you selected yes to the above question, please provide a date you will return to your site:*

MonthDayYear
Date
How you ethically and appropriately plan to conclude your time with your clients*
The status of all required documentation for your clients*
Any belongings that need to be returned to the site and how that will be accomplished*
A statement that you will delete any and all recordings of the site's clients by your final date there*
Any other termination/closing requirements that the site indicates to you*
Signature

Clear

Clinical Team Admin Page
Please add any other pertinent details to this student's withdrawal from site, course, or university as applicable:
File Upload

Cancelof
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This form is intended to provide National University with your plan to resign from a clinical site.

Students are able to leave sites, but they generally need to provide a month’s notice to their site. Please provide us with the responses below to the following, in order to ethically exit your site:

Clinical Team Admin Page