AUTHORIZATION FOR THE RELEASE AND REQUEST OF INFORMATION

I, __________________________________________ authorize __________________________________________________________

from the Counseling Center to release information to the following individual/entity:

Name: __________________________________________________________________________________________________________
Contact Information: __________________________________________________________________________________________
Regarding: _____________________________________________________________________________________________________
__________________________________________________________________________________________________________________
for the purpose of assisting with my academic program, planning and intervention.

By signing this consent form, I understand that I am giving my permission for my Counselor to
disclose information. I understand that authorization shall remain valid for one year or until
_____________________________ 20___ from the date of my signature below. I may revoke this
authorization by written communication to the BMCC Counseling Center director or my
counselor.

I certify that this form has been fully explained to me, that I understand its contents and that my
refusal to sign would in no way jeopardize the service I receive at the Counseling Center.

Confidentiality of your personal counseling information will be protected, as required by law (FERPA: 20
U.S.C. & 1232g; 34CFR Part 99) with access restricted to BMCC Counseling Center Counselors. Your personal
information would only be released to the concerned party when (1) you sign a release form for
referral/collaborative purposes, (2) a counselor assesses that you are in imminent danger and/or the situation
warrants immediate intervention, or (3) the Counseling Center is mandated by court order to release your
records.

_________________________________________________________ ____________________________________________________
Signature of Student Date Print Name of Student

DOB: __________/__________/____________ EMPLID#:_________________________________________

________________________________________________________ ____________________________________________________
Counselor’s Signature Date Print Name