Discussion List for campus-based and allied personnel working to end gender-based violence on campus.

[Gina Capra <>]

Good Afternoon All!

I am in the process of creating an 'Authorization to Release/ Exchange Confidential Information' form for the Simmons College Violence Prevention and Educational Outreach office.  

I have taken some language from our College's Counseling Center Release form, but realize that it does not include language that reflects my obligations to report disclosures to our Title IX Coordinator.  (My role is considered 'Private' versus 'Confidential' at Simmons).

I wouldn't ask students to sign this form before I share info with our Title IX Coordinator, but if they ever requested that I coordinate services with another service provider or office at the College, I would like to have them sign a release form before hand so that they have full control of who has their information.

Does anyone have a sample release form that does a really good job at explaining that while I am mandated to share info with our College's Title IX Coordinator, students' private information is otherwise kept confidential unless they fill out the form to request that I share info with someone specific?

Thank you!

Gina Capra

 

Program Coordinator 

Violence Prevention and Educational Outreach

Advisor to Betsy's Friends 

Simmons College

 

Room W-003

300 The Fenway

Boston, MA 02115

(P) 617-521-2118

(F) 617-521-3049

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