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.


  • Contact Information

  • Phone Number(s)



  • 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.

  • This field is for validation purposes and should be left unchanged.
  • School of the Art Institute of Chicago

    A leader in educating artists, designers, and scholars since 1866, the School of the Art Institute of Chicago (SAIC) offers nationally accredited undergraduate and graduate degrees and post-baccalaureate programs to 3,200 students from around the globe. Located in the heart of Chicago, SAIC has an educational philosophy built upon an interdisciplinary approach to art and design, giving students unparalleled opportunities to develop their creative and critical abilities, while working with faculty who are the leading practitioners in their fields.

    • 36 S. Wabash Ave.
      Chicago, IL 60603
    • admiss@saic.edu
    • 800.232.7242
    • 312.629.6100

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