Authorization to Disclose Limited Mental Health Information
This form allows you the opportunity to revoke the sharing of information you have provided to Counseling Services. As indicated in the Privacy Policy, your mental health information may be shared, on a limited basis, with Health Services or other professionals in Student Life to broaden the quality of your care. Disclosure of your information to other individuals or organizations is prohibited without your written consent.
Please indicate below how you want to authorize the sharing of your mental health information.
You have the right to change this authorization at any time.