Authorization for Release

Treating Professional's Information

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Treating Professional Name:

Treating Professional Phone:

Treating Professional Email:

Email address must be of a valid format.

Treating Professional Address:

Primary Reason for Withdrawal(Required):

This field is required.

College(Required):

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RC Student: male and/or Richmond-identifying; WC Student: female and/or Westhampton-identifying

Today's Date(Required):

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This date of submission, today's date, will serve as the start date for Authorization for Release.

Student Information

Name

ID Number

Authorization and Treating Health Professional Information

I understand that I MUST print, complete, and upload the Authorization for Release Form below in the "Upload your Authorization for Release Form here" section to authorize the health professional listed in this form to share confidential and relevant health information to the University by providing a treatment summary and necessary recommendations for the purpose of determining my readiness to return to Richmond, coordinating follow-up treatment, and developing an appropriate behavioral contract (if needed).(Required)

I understand

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Upload your Authorization for Release Forms here

Print, complete, and upload this Authorization for Release Form now. The form must be completed in full and signed. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

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Treating Professional's Information

Student Information

Authorization and Treating Health Professional Information

Upload your Authorization for Release Forms here

Submission