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.

Your Name(Required)

First Middle Last

Thank you for completing the Consent to Release Information form, authorizing the Marshall University Counseling Center to confirm your attendance in counseling sessions with the Title IX Office. This consent helps ensure that appropriate supportive measures can be implemented and monitored as part of the Title IX process. If you have any questions or concerns about this form or your rights under FERPA, please contact the Title IX Office.

Important Reminder: Online Reporting Strongly Preferred

Title IX Reporting - Online Submissions PREFERRED:

The Title IX Office prefers the submission of Title IX report through the online reporting system. It is preferred that all Title IX reports be submitted through our secure online form. This centralized process helps us review reports promptly, triage concerns efficiently, and ensure consistent and equitable responses for our campus community.

In‑person, email, and phone submissions are accepted on a limited basis as reporting methods for Title IX incidents. Those conversations may still occur for support purposes, but they do not constitute an official Title IX report.

Submit an Online Title IX Report

Please note: Due to staff availability, it may take up to five business days for your report to be reviewed.

If You Are in Crisis

Call 911 or contact the Marshall University Counseling Center for immediate support:
Prichard Hall, First Floor
304-696-3111
Marshall University Counseling

We appreciate your understanding and remain committed to supporting a safe, respectful, and inclusive campus environment.