Release of Information
Consent for the Release of Privileged Information Form
Privacy and confidentiality laws and policies prohibit information from being released
once an individual enters into a medical or counseling relationship with a licensed
professional. However, if the student is agreeable to signing the Release of Information Form (see link below), some limited information can be disclosed to the faculty or staff
member as directed by the student. For example, you may be interested to know whether
the student you referred made it to their first appointment. As an alternative to
simply asking your student face-to-face, you could print and complete the form (see
instructions below) with your student and mail or fax it to the Counseling Center.
Download the Release of Information From PDF
Completing the Release of Information Form:
- Ask the student to print his/her name and student number on the top line.
- Check the box 'Attendance at Counseling'.
- Check the box 'obtained from' at the center of the page.
- Under Name and Address of organization, insert Counseling Center, Ferris State University.
- Under 'revocation' line, insert date of three months from the time of completion of
- Have the student sign and date the document, and sign and date it yourself as the
Send it to the Counseling Center at the address on the Release or FAX it to 231.591.5336. Please call Nancy Sage, Secretary, or Paul Sullivan, Director,
at the Counseling Center for further information.