Release of Information. This form grants legal permission for Counseling & Psychological Services to share protected health information with another person or agency. Please be sure to complete the form entirely. Please call CPS at 740-593-1616 with your questions about the nature, purpose, or completion of this form.
Outreach Request Form
Client Consent For Treatment. This form covers important policies such as confidentiality, fees for services, and voluntary consent to participate in counseling. All persons seeking services at CPS must understand and complete this document. It is also available at the Front Desk.
*PENDING*Consent for Treatment of Minor. This form is completed by a parent or guardian when a student under the age of 18 wants to participate in counseling. The parent/guardian must also review the form above, Client Consent For Treatment, with their minor student. Note that Ohio Law permits persons 14 to 17 years of age to attend counseling for 30 days or 6 sessions, whichever comes first, without parent/guardian consent or knowledge.