Counseling Assessment Release Authorization Form

This form allows a student to authorize any current or prior counseling provider, mental‑health professional, treatment facility, or counseling agency to release a copy of the student’s counseling assessment to the Marshall University Title IX Office. This authorization may be used even when the student or the Title IX Office does not know the name of the provider at the time the form is completed. The information released may include the assessment itself, summary findings, recommendations, and confirmation of any required follow‑up associated with the assessment. This form does not authorize the release of psychotherapy notes, unless separately permitted under HIPAA. The Title IX Office requests this information solely for the purposes of: conducting safety and risk assessments; developing or updating a student support or success plan; verifying completion of requirements from a prior institution or process; and ensuring appropriate supportive measures are in place. By completing this form, the student provides written consent consistent with FERPA and HIPAA requirements for disclosure of educational and counseling‑related records. 2 The student may revoke this authorization at any time in writing, except where information has already been released in reliance on this consent. This authorization remains valid for one (1) year from the date of signature unless revoked earlier.

Purpose of This Form: This form authorizes any prior or current counseling provider, agency, clinician, evaluator, or mental‑health professional who conducted or participated in a counseling assessment for the student to release records to the Marshall University Title IX Office, even if the provider’s identity is not known at the time this form is signed. This authorization enables the Title IX Office to obtain a counseling assessment required or completed at another institution or by an outside provider, including any summary, evaluation, recommendations, or completion/attendance confirmations needed to complete an administrative review or develop a success plan.

Information about You

Your Name(Required)

First Middle Last

Student ID Number(Required)

Provide your Marshall University ID Number - If you do not have a MUID, just list Not Applicable (N/A).

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Date of Birth(Required)

Entities to Contact for Records(Required)

Please list any providers, agencies, or institutions that may have your counseling assessment or related records. If you do not know the name of the provider or entity, write “Unknown.”

Recipient of Information

The records authorized for release under this form may be disclosed to the Marshall University Title IX Office, specifically to the Title IX Coordinator at titleix@marshall.edu, for purposes related to safety planning, administrative review, or completion of required processes.

Records to Be Released to the Marshall University Title IX Office

The records described below may be released to the Marshall University Title IX Office, specifically to the Title IX Coordinator at titleix@marshall.edu.

Records Authorized for Release

This authorization permits the release of: 1. A counseling assessment completed as part of any institutional requirement, resolution process, probation requirement, or behavioral‑health review; 2. Any summary of findings, recommendations, or required follow‑up; 3. Confirmation of completion or participation in any counseling sessions required as part of that assessment; 4. Contact information necessary for verification or follow‑up; and 5. Any documentation needed to determine readiness, risk, or support considerations associated with my participation at Marshall University.

Purpose of Disclosure

The information will be used solely for: 1. Risk assessment and safety planning, 2. Development of a Student Success or Support Plan, 3. Understanding any recommendations necessary to support the student, and 4. Ensuring continued compliance with any prior institutional resolution requirements, when applicable.

Validity and Right to Revoke

This authorization is valid for one (1) year from the date signed below unless revoked earlier. I understand that: 1. I may revoke this authorization in writing at any time, except where records have already been released; 2. Revocation must be submitted to the Title IX Office; 3. Records disclosed prior to revocation cannot be retrieved; and 4. This authorization does not create a FERPA proxy and does not grant access to any unrelated academic records.

Today's Date (Date of Consent)(Required)

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Thank you for taking the time to fill out the Counseling Assessment Release Authorization Form.

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.