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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

  1. Download the correct file and save the blank form to your computer.
  2. Open the saved file on your computer and complete the form.
  3. Click on the signature icon (pen) on the menu section and create/drag your signature to the signature line.
  4. 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.
  5. Save the completed form and email it as an attachment to 7405930091@fax.ohio.edu.
  6. For security reasons, we encourage you delete the saved copy from your computer once you have received confirmation of receipt from CPS.

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.