STUDENT HEALTH & UNIVERSITY COUNSELING CENTER
STUDENT ACCESSIBILITY OFFICE (SAO)
CONSENT TO RELEASE INFORMATION
Regarding Our Information Forms and Service
The purpose of the following informational questionnaires is to obtain as comprehensive a picture of your background and con-
cerns as possible so that we may best service your needs. Please answer the questions as honestly and accurately as you can. All
records at the Counseling Center Student Accessibility Office are confidential.
We realize that the concerns you bring to our office are highly personal in nature. We assure you that all of the information shared
oth verbally and in writing will be managed within the legal and ethical conditions of confidentiality. This means that information
will not be released to anyone except under the following conditions:
1. When our counseling staff feel the need to seek supervision, we may consult with professional colleagues within our agency.
This will aid us in our work with you.
2. If we believe that you pose a life-threatening risk to yourself or someone else, we must notify responsible individuals to pre-
vent any harm from occurring.
3. If you are under 18 years of age and the victim of physical or sexual abuse, we are required to report relevant information to
child protective services to prevent further abuse from occurring. Additionally, if you disclose information regarding the
physical or sexual abuse of a minor, we are also required to report relevant information to child protective services.
4. If you are involved in a legal action and a judge determines that clinical information will provide evidence bearing significantly
on the case, he or she may subpoena or legally compel the therapist to release information from your records.
5. In case of any malpractice action against counselors on staff, the counselor may disclose information from the case that is nec-
essary or relevant to the counselor’s defense.
6. When your counselor is receiving supervision, a consent form to discuss your case with the supervisor will be fully discussed
and signed giving your consent to this.
7. For the purpose of evaluating our services, gathering valuable research information, and designing future programs, the Coun-
seling Center Student Accessibility Office staff may utilize your clinical information; however, your anonymity will be main-
tained through the use of a client identification number, which is different from any identifying data such as a social security or
student ID number.
8. All counseling records may be stored on a secured computer system. n If this occurs, confidentiality will be maintained
through Novell Security and database security roles.
9. All case files are the property of the University Counseling Center Student Accessibility Office.
In all other situations, information may be released to appropriate individuals or agencies ONLY UPON YOUR WRITTEN REQUEST.
I have read and understand that these conditions of confidentiality apply to being identified as a client, as well as any information
shared verbally or in writing to my counselor.
If you have any questions about this form, your intake counselor will be glad to discuss the information with you.