THE COUNSELING SERVICE

SOUTH DAKOTA SCHOOL OF MINES & TECHNOLOGY, ROOM 6, SURBECK CENTER
RAPID CITY, SOUTH DAKOTA 57701, PHONE 605-394-1924
INFORMATION REQUEST

I, ______________________________________, hereby authorize

___________________________________________, to disclose the
  (name and address of person and/or agency)

information checked below to The Counseling Service.

INFORMATION RELEASE.

I, _____________________________________, hereby authorize
The Counseling Service to release the information checked below to

_____________________________________________________________________________
   (name and address of person and/or agency)

_____________________________________________________________________________

A Counseling Service staff member has explained to me: who is to receive this information, and
the type of information to be requested/released.

RECEIVER OF INFORMATION PURPOSE TYPE OF INFORMATION
_____ CS Staff ____ To assist in my treatment ______ Medical and treatment information
_____ Other ____ To assure adequate coordination of treatment efforts ______ Treatment plan information
____ Other ______ Psychological testing and evaluation
______ Discharge summary
______ School Records
______ Other (specified)

My authorization in this matter is given for the following time period: ________________
And will not be valid after the end of this period unless I renew the authorization.

I understand that I may cancel this authorization at any time, except that I cannot
Cancel actions taken on the basis of information given out prior to cancellation.

SIGNATURE OF CLIENT: _________________________________ DATE:__________

SIGNATURE OF WITNESS: _______________________________ DATE: _________