NYU Authorization for Release of Counseling Information 2015-2025 free printable template

Instructions for Requesting a Copy of your Health Record CLINICAL RECORDS: Please be advised that in order to obtain a copy of your clinical health record, you must complete the form Authorization

How to fill out release counseling information form

How to fill out NYU Authorization for Release of Counseling Information

1. Obtain the NYU Authorization for Release of Counseling Information form from the NYU Counseling Center website or office.
2. Read the instructions provided on the form carefully to ensure understanding of the process.
3. Complete the patient information section by providing your full name, date of birth, and student identification number.
4. Specify the recipient of the counseling information, including their name and contact details.
5. Indicate the purpose of the release, ensuring it aligns with your intentions for sharing your information.
6. Select the type of counseling information you wish to release, such as therapy notes, treatment summaries, or appointment details.
7. Check the boxes to indicate any limitations on the release, if applicable.
8. Sign and date the authorization form to indicate your consent.
9. Submit the completed form to the NYU Counseling Center by handing it in person or sending it via secure email.

Who needs NYU Authorization for Release of Counseling Information?

1. Students who wish to share their counseling information with third parties, such as medical professionals or family members, need the NYU Authorization for Release of Counseling Information.
2. Individuals applying for jobs or internships that require disclosure of mental health history may need to provide this authorization.
3. Students seeking to coordinate care with other healthcare providers may also require this authorization.

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What is NYU Authorization for Release of Counseling Information?

The NYU Authorization for Release of Counseling Information is a document that allows for the sharing of a student's counseling records with specified individuals or entities, ensuring that confidentiality is maintained while enabling necessary communication.

Who is required to file NYU Authorization for Release of Counseling Information?

Students who wish to allow their counseling information to be shared with family members, healthcare providers, or other parties are required to file the NYU Authorization for Release of Counseling Information.

How to fill out NYU Authorization for Release of Counseling Information?

To fill out the NYU Authorization for Release of Counseling Information, students must complete the required form by providing their personal details, specifying the information to be released, identifying the recipient(s) of the information, and signing and dating the form.

What is the purpose of NYU Authorization for Release of Counseling Information?

The purpose of the NYU Authorization for Release of Counseling Information is to obtain consent from students to share their counseling information with designated individuals or organizations for purposes such as medical care, family communication, or legal matters.

What information must be reported on NYU Authorization for Release of Counseling Information?

The information that must be reported on the NYU Authorization for Release of Counseling Information includes the student's name, date of birth, specific counseling information to be released, names of the recipients, the purpose for the release, and the student's signature and date.