Mental health Lang Wellness Center Health Documents

Lang Wellness Center Mental Health Disclosure

The following form will be used to send secure HIPAA compliant documents to the Rockford University Lang Wellness Center.
Due date for students starting in the Fall Semester:

September 1

Due date for students starting in the Spring Semester:

February 1
Full Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Rockford University Email*
example@Rockford.edu

Student Optional Disclosure of Private Mental Health Act
In accordance with the Student Optional Disclosure of Private Mental Health Act (110 ILCS 74), Rockford University is providing students the opportunity to authorize, in writing, the disclosure of certain private mental health information to a designated person of their choosing.

This Act states that an institution of higher learning may disclose mental health information if a physician, clinical psychologist, or qualified examiner, makes a determination that the student poses a clear danger to himself, herself or others to protect the student or other person against a clear, imminent risk of serious physical or mental injury or disease or death being inflicted upon the person or by the student on himself, herself, or another. The physician, clinical psychologist, or qualified examiner shall, as soon as practicable, but in no more than 24 hours after making the
determination under this section, attempt to contact the designated person and notify the designated person that the physician, clinical psychologist, or qualified examiner has made a determination that the student poses a clear, imminent danger to himself, herself, or others.

The form below provides you, as a student at Rockford University, with this opportunity as determined by the law. It asks you to designate an adult whom you would like us to contact in the event that you experience a mental health emergency that puts you or others at risk for serious injury or death. You are not required to designate a contact. However, should you choose to designate someone, it can be anyone over the age of 18 (parent, relative, sibling, family friend, or other adult). Please note too, that under certain circumstances as allowed or required by law, certain University officials may contact parents or others in the event of an emergency to protect the student’s life or the lives of others without the student’s express written consent. Students who wish to take the opportunity to give another individual authorization to disclose private mental health information must complete this Designated Person Form below.
Designated Person Form
Please check the box to indicate the action you would like to take:*

I would like to designate one individual as a contact in the event that I am evaluated by a licensed counselor, physician, or qualified examiner.I have previously identified a contact, but would now like to change to a new contact.I have previously identified a contact, and would like to rescind the name of contact (you will no longer have a contact on file).I DO NOT want to designate a person as a contact in the event that I am evaluated by a licensed counselor, physician, or qualified examiner. I do understand that I can change my mind at any time and complete this form in the future. I also understand that under certain circumstances as allowed or required by law, certain university officials may contact my parents or others in the event of an emergency to protect my life or the lives of others without my express written consent.
I would like the University to contact the following person in the event that I am evaluated by a licensed counselor, physician, 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.

Release Information to the following Designated Person
Designated Contact Name*

First NameLast Name
Designated Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Designated Contact Phone Number*
Please enter a valid phone number.
Designated Contact Email
example@example.com
Designated Person's Relationship to you:
Student Signature*

Clear
Lang Wellness Center

815-226-4083

HealthCenter@Rockford.edu
Should be Empty:

Lang Wellness Center Mental Health Disclosure

Student Optional Disclosure of Private Mental Health Act

Designated Person Form