SAIC Forms Student Optional Disclosure of Private Mental Health Information

Authorization Form
The Student Optional Disclosure of Private Mental Health Act is an Illinois law that provides college students with the opportunity to designate a contact person (an adult) in the event that a clinical psychologist or qualified examiner employed by SAIC makes a determination that the student poses a clear danger to themselves or others. Please note: You are not required to designate a contact. However, should you choose to designate a contact, that person must be someone over the age of 18 (e.g., parent, friend, sibling). Please initial one of the lines below, sign and date this form, and click submit. The information you provide will then be sent to Counseling Services.
Mental health contact person
- I would like to designate the following adult as a contact person in the event that I am determined by an SAIC clinical psychologist or qualified examiner as being a clear danger to myself or to others. I also understand that I can change this designation, or decline to name a contact at any time by completing this form again.
- I do not want to designate a mental health emergency contact person at this time. I understand that I can change my mind at any time and designate someone by completing another authorization form.
Contact Information
Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number(s)
Home
Cell
Work
Email
Relationship to student

Signature

Name

First Last

ID Number

Signature

Please note that, as allowed or required by law, SAIC may contact your parent or others without your express written consent in the event of a health or safety emergency.

Phone

This field is for validation purposes and should be left unchanged.

Authorization Form

Contact Information

Phone Number(s)

Signature