Forms
Release of Information
The Release of Information Form grants legal permission for Counseling & Psychological Services (CPS) to share protected health information with another person or agency.
- Complete the form entirely
- Call CPS at (740) 593-1616 with questions about the nature, purpose, or completion of the form
- Follow the directions for proper submission of the form
Call your clinician or CPS if assistance is needed when filling out this form.
Digital Signature and Submission
- Download the correct file and save the blank form to your computer.
- Open the saved file on your computer and complete the form.
- Click on the signature icon (pen) on the menu section and create/drag your signature to the signature line.
- In the absence of a witness signature, you need to speak with a CPS clinician to verify your identity and request for release of information.
- Save the completed form and email it as an attachment to 7405930091@fax.ohio.edu.
- For security reasons, we encourage you delete the saved copy from your computer once you have received confirmation of receipt from CPS.
Counseling and Psychological Services
Fillable Release of Information | CPS (Digital Signature)
Fillable Release of Information | CPS (Printed Signature)
Printable Release of Information | CPS
Eating Disorder Support Team
Consent for Treatment of Minor
- Complete the form entirely
- Call CPS at (740) 593-1616 with questions about the nature, purpose, or completion of the form
- Follow the directions for proper submission of the form
Call your clinician or CPS if assistance is needed when filling out this form.
Consent for Non-Student Partner in Couples Counseling
- Complete the form entirely
- Call CPS at (740) 593-1616 with questions about the nature, purpose, or completion of the form
- Follow the directions for proper submission of the form
Call your clinician or CPS if assistance is needed when filling out this form.
