Student Optional Disclosure of Private Mental Health Information

State law provides you with the opportunity to designate an adult whom you would like us to contact in the event that you experience a mental health emergency that puts you or others at risk for serious injury or death. You are not required to designate a contact. Should you choose to designate someone, it can be anyone over the age of 18 (parent, relative, sibling, family friend etc.).

Today's Date Today's Date * / MM / DD YYYY
Your Name Your Name * First Last
Your E-Number *
Birthday Birthday / MM / DD YYYY
Please check the box to indicate the action you would like to take.

Please check the box to indicate the action you would like to take. I would like to designate one individual as a contact in the event that I am evaluated by an EIU physician or qualified examiner. I have previously identified a contact, but would now like to change to a new contact. I have previously identified a contact, and would like to decline a name of contact (you will no longer have a contact on file). I DO NOT want to designate a person as a contact in the event that I am evaluated by an EIU physician or qualified examiner. I do understand that I can change my mind at anytime and complete this form in the future. I also understand that under certain circumstances as allowed or required by law, certain university officials may contact my parents or others in the event of an emergency to protect my life or the lives of others without my express written consent.
By checking the below box, I would like the university to contact the following person in the event that I am evaluated by an EIU physician or qualified examiner as being a clear danger to myself or to others. I also understand that I can change this designation, or decline to name a contact at any time by completing this form again.

By checking the below box, I would like the university to contact the following person in the event that I am evaluated by an EIU physician or qualified examiner as being a clear danger to myself or to others. I also understand that I can change this designation, or decline to name a contact at any time by completing this form again. Yes, the university may contact the following person.
Designated Person's Name Designated Person's Name First Last
Designated Person's Address Designated Person's Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Designated Person's Phone Designated Person's Phone - ### - ### ####
Designated Person's Email
Designated Person's Relationship to You