Release of Information Form for Academics

University of Louisiana at Monroe
Counseling Center

PERMISSION TO RELEASE INFORMATION

I give my permission to the ULM Counseling Center to release special need information to my instructors for the:

Semester *

Year *

This information is for professional purposes only and is confidential in nature.

Name: *

Date: *

Month

Day

Year

Phone: *

CWID: *

Date of Birth: *

Month

Day

Year

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