{"id":1578,"date":"2026-03-10T13:05:34","date_gmt":"2026-03-10T17:05:34","guid":{"rendered":"https:\/\/www.marshall.edu\/titleix\/?page_id=1578"},"modified":"2026-03-10T15:23:12","modified_gmt":"2026-03-10T19:23:12","slug":"counseling-assessment-release-authorization-form","status":"publish","type":"page","link":"https:\/\/www.marshall.edu\/titleix\/counseling-assessment-release-authorization-form\/","title":{"rendered":"Counseling Assessment Release Authorization Form"},"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_44' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Counseling Assessment Release Authorization Form<\/h2>\n                            <p class='gform_description'>This form allows a student to authorize any current or prior counseling provider, mental\u2011health professional, treatment facility, or counseling agency to release a copy of the student\u2019s 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.\r\nThe information released may include the assessment itself, summary findings, recommendations, and confirmation of any required follow\u2011up associated with the assessment. This form does not authorize the release of psychotherapy notes, unless separately permitted under HIPAA.\r\nThe Title IX Office requests this information solely for the purposes of:\r\n\r\nconducting safety and risk assessments;\r\ndeveloping or updating a student support or success plan;\r\nverifying completion of requirements from a prior institution or process; and\r\nensuring appropriate supportive measures are in place.\r\n\r\nBy completing this form, the student provides written consent consistent with FERPA and HIPAA requirements for disclosure of educational and counseling\u2011related 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.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_44'  action='\/titleix\/wp-json\/wp\/v2\/pages\/1578' data-formid='44' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_44' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_44_52\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><div class='gsection_description' id='gfield_description_44_52'>Purpose of This Form:\nThis form authorizes any prior or current counseling provider, agency, clinician, evaluator, or mental\u2011health 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\u2019s 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.<\/div><\/div><div id=\"field_44_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_44_1\" 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_44_1'>\n                            \n                            <span id='input_44_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_44_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_1.3' id='input_44_1_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            <span id='input_44_1_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_44_1_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                    <input type='text' name='input_1.4' id='input_44_1_4' value=''   aria-required='false'    autocomplete=\"additional-name\" \/>\n                                                <\/span>\n                            <span id='input_44_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_44_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_1.6' id='input_44_1_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_44_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible text-input\"  data-field-class=\"text-input\" ><label class='gfield_label gform-field-label' for='input_44_18'>Student ID Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_44_18'>Provide your Marshall University ID Number - If you do not have a MUID, just list Not Applicable (N\/A).<\/div><div class='ginput_container ginput_container_text'><input name='input_18' id='input_44_18' type='text' value='' class='large'  aria-describedby=\"gfield_description_44_18\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_44_2\" class=\"gfield gfield--type-email gfield--input-type-email 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 Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_44_2_container'>\n                                <span id='input_44_2_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_44_2' class='gform-field-label gform-field-label--type-sub '>Email Address<\/label>\n                                    <input class='' type='email' name='input_2' id='input_44_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <span id='input_44_2_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_44_2_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email Address<\/label>\n                                    <input class='' type='email' name='input_2_2' id='input_44_2_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_44_5\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_44_5'>Your Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_44_5' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"tel\" \/><\/div><\/div><div id=\"field_44_68\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_44_68'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_68' id='input_44_68' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_44_68_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_44_68_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_44_68' class='gform_hidden' value='https:\/\/www.marshall.edu\/titleix\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_44_67\" class=\"gfield gfield--type-post_content gfield--input-type-post_content gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_44_67'>Entities to Contact for Records<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_44_67'>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 \u201cUnknown.\u201d<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_67' id='input_44_67' class='textarea large'  aria-describedby=\"gfield_description_44_67\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_44_69\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Recipient of Information<\/h3><div class='gsection_description' id='gfield_description_44_69'>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.<\/div><\/div><div id=\"field_44_66\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Records to Be Released to the Marshall University Title IX Office<\/h3><div class='gsection_description' id='gfield_description_44_66'>\nThe records described below may be released to the Marshall University Title IX Office, specifically to the Title IX Coordinator at titleix@marshall.edu.<\/div><\/div><div id=\"field_44_71\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Records Authorized for Release<\/h3><div class='gsection_description' id='gfield_description_44_71'>This authorization permits the release of:\n\n1. A counseling assessment completed as part of any institutional requirement, resolution process, probation requirement, or behavioral\u2011health review;\n2. Any summary of findings, recommendations, or required follow\u2011up;\n3. Confirmation of completion or participation in any counseling sessions required as part of that assessment;\n4. Contact information necessary for verification or follow\u2011up; and\n5. Any documentation needed to determine readiness, risk, or support considerations associated with my participation at Marshall University.<\/div><\/div><div id=\"field_44_8\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Purpose of Disclosure<\/h3><div class='gsection_description' id='gfield_description_44_8'>The information will be used solely for:\n\n1. Risk assessment and safety planning,\n2. Development of a Student Success or Support Plan,\n3. Understanding any recommendations necessary to support the student, and\n4. Ensuring continued compliance with any prior institutional resolution requirements, when applicable.<\/div><\/div><div id=\"field_44_70\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Validity and Right to Revoke<\/h3><div class='gsection_description' id='gfield_description_44_70'>This authorization is valid for one (1) year from the date signed below unless revoked earlier. I understand that:\n\n1. I may revoke this authorization in writing at any time, except where records have already been released;\n2. Revocation must be submitted to the Title IX Office;\n3. Records disclosed prior to revocation cannot be retrieved; and\n4. This authorization does not create a FERPA proxy and does not grant access to any unrelated academic records.<\/div><\/div><fieldset id=\"field_44_63\" 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' >Certification<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_63.1' id='input_44_63_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_44_63_1' >By clicking the checkbox, I certify that: 1. I am the student named above and the individual completing this form; 2. I voluntarily authorize the release of the counseling assessment information described in this form; 3. I understand my rights under FERPA and HIPAA, including my right to revoke this authorization; and 4. I consent to the disclosure of my counseling assessment records from any counseling provider, agency, or institution, including those whose names may be unknown or not listed at the time of submission.<\/label><input type='hidden' name='input_63.2' value='By clicking the checkbox, I certify that: 1. I am the student named above and the individual completing this form; 2. I voluntarily authorize the release of the counseling assessment information described in this form; 3. I understand my rights under FERPA and HIPAA, including my right to revoke this authorization; and 4. I consent to the disclosure of my counseling assessment records from any counseling provider, agency, or institution, including those whose names may be unknown or not listed at the time of submission.' class='gform_hidden' \/><input type='hidden' name='input_63.3' value='22' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_44_72\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_44_72'>Today&#039;s Date (Date of Consent)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_72' id='input_44_72' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_44_72_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_44_72_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_44_72' class='gform_hidden' value='https:\/\/www.marshall.edu\/titleix\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_44_49\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_44_49'>CAPTCHA<\/label><div id='input_44_49' class='ginput_container ginput_recaptcha' data-sitekey='6LcJtEQiAAAAAP_vuQ362iVBQS2x9xrCp_cm3msg'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/div><div id=\"field_44_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 taking the time to fill out the Counseling Assessment Release Authorization Form.<\/h3><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button class=\"mx-auto inline-flex justify-center items-center space-x-2 bg-green text-white hover:text-white hover:bg-green-dark no-underline text-xl font-bold uppercase rounded-sm py-2 px-4 lg:py-3 lg:px-6 text-center transition-all duration-150 ease-in-out dark:text-gray-900 dark:hover:text-gray-900 group\"  type='submit' id='gform_submit_button_44' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' 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