Consent for MU Counseling Center to Release Information to MU Title IX Office

Consent for Marshall University Counseling Center to Release Information to Marshall University Title IX Office

This form authorizes the Marshall University Counseling Center to share limited information with the Title IX Office regarding a student’s attendance in counseling sessions. This disclosure is made solely for the purpose of supporting the student through the Title IX process, including monitoring and implementing supportive measures. By signing this form, the student consents to the release of information confirming whether they are attending counseling. No details about the content of counseling sessions will be disclosed. This consent is valid for one (1) year from the date of signature and may be revoked at any time in writing.

Information about You

Your Name(Required)

First Middle Last

Student ID Number(Required)

Provide your Marshall University ID Number.

Preferred Name / Pronouns(Required)

List your preferred name and pronouns.

Date of Birth(Required)

Purpose of Disclosure: To assist the Title IX Office in implementing and monitoring supportive measures and/or accommodations related to a Title IX matter.

Recipient of Information: Marshall University Title IX Office.

This consent is valid for one (1) year from the date of signature unless revoked in writing earlier. I understand that I may revoke this consent at any time by submitting a written request to the Title IX Office, except to the extent that action has already been taken in reliance on this consent.