Release of Information (ROI) Form
The Counseling Center staff cannot disclose/share your Protected Health Information (PHI) without your prior consent. If you would like copies of your counseling records, or would like information from your records shared with another party, you must first submit a completed ROI (below):
The completed ROI can be faxed to (603) 646-9506 (ATTN: Counseling Center) or emailed to the Counseling Center.
*At this time we do not accept electronic signatures. Please print the ROI, fill it out and sign it, then scan and email or fax to the Counseling Center.