{"id":1381,"date":"2025-07-23T14:59:38","date_gmt":"2025-07-23T18:59:38","guid":{"rendered":"https:\/\/www.marshall.edu\/titleix\/?page_id=1381"},"modified":"2025-07-23T14:59:38","modified_gmt":"2025-07-23T18:59:38","slug":"consent-for-mu-counseling-center-to-release-information-to-mu-title-ix-office","status":"publish","type":"page","link":"https:\/\/www.marshall.edu\/titleix\/consent-for-mu-counseling-center-to-release-information-to-mu-title-ix-office\/","title":{"rendered":"Consent for MU Counseling Center to Release Information to MU Title IX Office"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_32' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Consent for Marshall University Counseling Center to Release Information to Marshall University Title IX Office<\/h2>\n                            <p class='gform_description'>This form authorizes the Marshall University Counseling Center to share limited information with the Title IX Office regarding a student\u2019s 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.\r\n\r\nBy 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.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_32'  action='\/titleix\/wp-json\/wp\/v2\/pages\/1381' data-formid='32' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_32' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_32_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Information about You<\/h3><\/div><fieldset id=\"field_32_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Your Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_32_1'>\n                            \n                            <span id='input_32_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_32_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_1.3' id='input_32_1_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            <span id='input_32_1_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_32_1_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                    <input type='text' name='input_1.4' id='input_32_1_4' value=''   aria-required='false'    autocomplete=\"additional-name\" \/>\n                                                <\/span>\n                            <span id='input_32_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_32_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_1.6' id='input_32_1_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_32_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible text-input\"  data-field-class=\"text-input\" ><label class='gfield_label gform-field-label' for='input_32_18'>Student ID Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_32_18' type='text' value='' class='large'  aria-describedby=\"gfield_description_32_18\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_32_18'>Provide your Marshall University ID Number.<\/div><\/div><div id=\"field_32_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible text-input\"  data-field-class=\"text-input\" ><label class='gfield_label gform-field-label' for='input_32_19'>Preferred Name \/ Pronouns<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_32_19' type='text' value='' class='large'  aria-describedby=\"gfield_description_32_19\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_32_19'>List your preferred name and pronouns.<\/div><\/div><div id=\"field_32_65\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible text-input\"  data-field-class=\"text-input\" ><label class='gfield_label gform-field-label' for='input_32_65'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_32_65' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_32_67\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_67.1' id='input_32_67_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_32_67\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_32_67_1' >I, the undersigned, hereby authorize the Marshall University Counseling Center to disclose the following information to the Marshall University Title IX Office:<\/label><input type='hidden' name='input_67.2' value='I, the undersigned, hereby authorize the Marshall University Counseling Center to disclose the following information to the Marshall University Title IX Office:' class='gform_hidden' \/><input type='hidden' name='input_67.3' value='17' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_32_67' tabindex='0'>\u2022\tConfirmation of whether I am attending counseling sessions.<\/div><\/fieldset><div id=\"field_32_70\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Purpose of Disclosure: To assist the Title IX Office in implementing and monitoring supportive measures and\/or accommodations related to a Title IX matter.<\/h3><\/div><div id=\"field_32_71\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Recipient of Information: Marshall University Title IX Office.<\/h3><\/div><div id=\"field_32_72\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">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.<\/h3><\/div><fieldset id=\"field_32_56\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Your Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_32_56'>\n                            \n                            <span id='input_32_56_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_32_56_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_56.3' id='input_32_56_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            <span id='input_32_56_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_32_56_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                    <input type='text' name='input_56.4' id='input_32_56_4' value=''   aria-required='false'    autocomplete=\"additional-name\" \/>\n                                                <\/span>\n                            <span id='input_32_56_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_32_56_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_56.6' id='input_32_56_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_32_48\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Certify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_48.1' id='input_32_48_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_32_48_1' >By entering my name above, I certify that I am the individual completing this form and that the information provided is accurate. I voluntarily authorize the Marshall University Counseling Center to confirm my attendance in counseling sessions with the Marshall University Title IX Office, as described in this form.  I understand that this consent is valid for one (1) calendar year from the date of submission and may be revoked at any time in writing.<\/label><input type='hidden' name='input_48.2' value='By entering my name above, I certify that I am the individual completing this form and that the information provided is accurate. I voluntarily authorize the Marshall University Counseling Center to confirm my attendance in counseling sessions with the Marshall University Title IX Office, as described in this form.  I understand that this consent is valid for one (1) calendar year from the date of submission and may be revoked at any time in writing.' class='gform_hidden' \/><input type='hidden' name='input_48.3' value='17' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_32_51\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">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. 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