Release of Information Form for Residential Life

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 Residential Life for the:

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

CAPTCHA
This question is for testing whether you are a human visitor and to prevent automated spam submissions.
  _____  _____           _____          __  __
|__ / |_ _| _ _ |___ | _ _ \ \/ /
/ / | | | | | | / / | | | | \ /
/ /_ | | | |_| | / / | |_| | / \
/____| |_| \__, | /_/ \__, | /_/\_\
|___/ |___/
Enter the code depicted in ASCII art style.