Fillable Counseling Center State University of New York at (State University of New York at Fredonia)

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Counseling Center State University of New York at (State University of New York at Fredonia)

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The Counseling Center State University of New York at (State University of New York at Fredonia) form is 1 page long and contains:

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  • 26 check-boxes
  • 23 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State University of New York at Fredonia

BROWSE STATE UNIVERSITY OF NEW YORK AT FREDONIA FORMS

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Counseling Center
State University of New York at Fredonia
280 Central Avenue, LoGrasso Hall,
Fredonia, NY 14063
PHONE (716) 673-3424
FAX (716) 673-3140
AUTHORIZATION FOR RELEASE OF INFORMATION
I, ____________________________________, DOB: ____________ , Fredonia ID #: ____________________do hereby
request that the Counseling Center engage in the following as it relates to my records.
Please have the following information (check one)
☐obtained/☐released /☐exchanged
(check one)
☐from☐ to ☐with the SUNY Fredonia Counseling Center to the following person/provider/agency:
____________________________ ____________________________ ____________________________
Person/provider/title Name of agency/affiliation Phone/ Fax Number
_______________________________________________________________________________
Mailing address: street, city, and zip code
Purpose of Disclosure:
☐Coordination of care ☐Personal knowledge ☐Legal ☐Employment ☐Insurance ☐Other: ________________
(Check all desired)
COUNSELING RECORDS
☐Dates of service
☐Counseling summary
☐Initial evaluation
☐Assessment Information
☐Progress notes
☐Counseling recommendations
☐Referrals made
☐Other______________________________________
PSYCHIATRIC/MEDICAL RECORDS
☐Labs
☐Medications prescribed
☐Diagnosis
☐Dates of service
☐Other________________________
☐Exclusions (items not to be
disclosed):___________________________________
I understand this authorization is voluntary and not a condition of treatment. This authorization is
automatically void after 1 year, and may be terminated by me at any time with a written notice, effective as of
the date of signature. Information sent and/or received through this authorization may not be re-released to
another individual or agency
. Date of Revocation ___________________
_____________________________________________ _________________________
Signature of client Date
For use by Notary Public if returned by fax or mail: State of __________ County of______________________
Before me, the undersigned notary public, this day, personally, appeared _____________________________
___________________________to be known, who being duly sworn according to law, deposes the following:
__________________________________________ (Signature of Affiant)
Subscribed and sworn to before me this ______________ day of ______________________, 20___________.
Notary Public _______________________________________ My Commission expires: _________________
_________________________________________________________________________________________
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Counseling Center State University of New York at (State University of New York at Fredonia)

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Completed 1 February 2021

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