Ohio University

Forms

Release of Information form

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. Follow the directions on the form as to how to submit this form to CPS after you have completed.

Printable Release of Information form: Please print, complete the form in its entirety (if not sure how to fill this form, contact your clinician or CPS - 740-593-1616, for assistance). Once completed, you can either fax it to CPS – 740-593-0091 or scan to your computer and email it to CPS: 7405930091@fax.ohio.edu For security reasons, we encourage you delete the saved copy from your computer once it is received by CPS.

Fillable PDF Release of Information with digital signature. Call CPS or your clinician for assistance when filling out this form. You need Adobe (Acrobat Reader) to create a digital signature. 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. You need to save this to your computer and then email it to CPS: 7405930091@fax.ohio.edu For security reasons, we encourage you delete the saved copy from your computer once it is received by CPS.

Fillable PDF Release of Information with printed signature. Call your clinician or CPS (740-593-1616) for any assistance needed when filling out this form.  When signing, you need to 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. You need to save this to your computer and then email it to CPS: 7405930091@fax.ohio.edu For security reasons, we encourage you delete the saved copy from your computer once it is received by CPS.

Consent for Treatment of Minor form

Printable Consent for Treatment of Minor form: Please print, complete the form. Contact your clinician or CPS - 740-593-1616, for assistance. Once completed, you can either fax it to CPS –- 740-593-0091 or scan to your computer and email it to CPS: 7405930091@fax.ohio.edu For security reasons, we encourage you delete the saved copy from your computer once it is received by CPS.

Fillable PDF Consent for Treatment of Minor form: Call your clinician or CPS (740-593-1616) for any assistance needed when filling out this form.  When signing, you need to click on the signature icon (pen) on the menu section and create/drag your signature to the signature line. You need to save this to your computer and then email it to CPS: 7405930091@fax.ohio.edu For security reasons, we encourage you delete the saved copy from your computer once it is received by CPS.

Training Request forms

Outreach Training Request

Bobcats Who Care Training Request