If you would like Counseling and Human Development staff to disclose/share your Protected Health Information with an outside source, please download and complete this pdf document and either mail or fax it ATTN: CHD (Counseling and Human Development). Our contact information is on the form. Your signature is required.
Generally, students wish to release "information pertaining to my treatment at CHD/Dick’s House" to an outside source, which may be another office on campus (such as the Dean’s Office, Judicial Affairs, Residential Life, Academic Skills Center Staff, etc.) or off campus (such as parents, doctors/therapists, etc.).
The purposes of such requests vary, but some examples are: Continuity of Care, Information Sharing, Notice that I attended my required drug/alcohol assessment (if so, be sure to initial "I do" under statement #1), Support for: Medical Withdrawal, Psychiatric Disability, Special housing needs, COS Hearing, Academic Support Needs.
You will need to sign your name and date the form in addition to printing your full name, graduation year and birth date. You can contact our office if you have questions at 603-646-9442.
Last Updated: 3/1/13