Section 1: Fill in your name, date of birth, contact phone number, and graduation year
Section 2: Select the information you would like disclosed:
- Counseling treatment records: If checked, all clinical counseling session notes and DP2 (athletics) consultation records will be released to the designee in Section #3.
- Medication management records: If checked, all session notes related to medication prescription management will be released to the designee in Section #3.
- Information needed to coordinate academic consideration: If checked, treatment information can be relayed to campus offices such as: Student Accessibility Services, Academic Skills Center, Deans Office, Community Standards and Accountability Office, etc.
- Eating Disorder Team coordination of care: If checked, you are giving permission for the Dick's House Eating Disorder Team to coordinate care with your home/community provider(s).
- Nutrition treatment records: If checked, all nutrition session notes will be released to the designee in Section #3.
Section 3: Select to whom are releasing your Protected Health Information (PHI):
- If you would like records released to yourself, parents/other family, or an outside treatment provider, fill in the recipient's name, address, phone number, and fax number.
- IMPORTANT: During the COVID-19 pandemic, counseling records will be faxed or emailed to the recipient. Please include a legible fax or email on the ROI.
Section 4: Indicate the purpose of the disclosure
Authorization Expiration Date: If an expiration date is not indicated, the ROI will expire one year from the 'date signed'.
Signature and Date Signed
- Please be sure to sign and date the ROI (electronic signature is acceptable).
Fax the completed ROI to (603) 646-9506, or email to Counseling@Dartmouth.edu. Please allow up to 2 weeks for processing.
Please contact the Counseling Center at (603) 646-9442 with any questions.