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Health and Counseling Forms





Authorization to Treat:

Authorization to Treat Form (1)revised513.docxAuthorization to Treat Form


Student Release Authorization:

StudentReleaseAuthorizationpdf.pdfStudent Release Authorization


Student Health Care Center Satisfaction Survey:

SHCPatientSatisfactionSurveypdf.pdfSHC Patient Satisfaction Survey 


Acknowledgment of Privacy Practices

PrivacyPracticesAcknowledgement.Revised.docxPrivacy Practices Acknowledgement

RAPcounselingnoticeofprivacypractices.docxNotice of Privacy Practices


Vaccination Refusal/Exception Form
RefusalExemption to Vaccinate_April 13 2016.pdfRefusal Exemption to Vaccinate

Travel Health Advisory Form

Travel Information_updated june 2015.pdfTravel Information

Student Medical Examination Record Form

Medical Form_Revised FEB 2017.pdfStudent Medical Examination Record Form







 Student of Concern:

Student of Concern Form


Release of Information:

CounselingGeneralReleasepdf.pdfCounseling General Release









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