Disclosure of Private Mental Health Information Reporting Form

Date of Submission

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Date Submitted(Required):

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Background Information

Your Full Name

Select Student

UIN

Phone number

Email address

Designated Contact Person's Information and Options

Please complete the following part if you are authorizing the released of information to a designated person in case of a mental health emergency. By completing the information below, you are authorizing that the University of Illinois Springfield has permission to contact a designated person in the event that you are evaluated by a University of Illinois Springfield psychologist, counselor, or other qualified examiner, and they determine that you are in clear danger to yourself or to others. You also understand that you can change this authorization at any time by completing this form again on the website.

Additionally, please selection one box to indicate the option you would like to take.

Designated Contact Person's Name(Required) This field is required.

Relationship to You(Required) This field is required.

Phone Number(Required) This field is required.

Email Address(Required) This field is required.

Address(Required) This field is required.

Please indicate your Mental Health Designation below:(Required)

I would like to designate one individual as a contact in the event of a mental health emergency where I am evaluated by a University of Illinois Springfield psychologist, counselor, or other qualified examiner. I have previously designated a contact, but would like to change to a new designated person to contact. I have previously designated a contact, but would now like to decline authorization (you will no longer have a contact on file). I DO NOT want to designate a person to contact in the event of a mental health emergency. I do understand that I can change my mind at anytime and designate a contact person in the future. I also understand that under certain circumstances as allowed and/or required by law, University of Illinois Springfield officials may contact my parents or others in the event of an emergency to protect my life or the lives of others without my expressed written consent.

This field is required.