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Forms

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Below are the commonly used forms in the Counseling Clinic. These forms can also be accessed by going to the Counseling Clinic in the Human Services Building or talking directly to your counselor.  These forms may be printed out and brought to the Counseling Clinic or emailed to the Associate Director at jacobert@eiu.edu or Office Administrator at garyan@eiu.edu 

Release of Information: 

At the EIU Counseling Clinic, we support student well-being through coordinated care with relevant campus and community providers. With your consent, we may exchange limited, relevant information to support your emotional, academic, and personal success. This form authorizes the disclosure and/or exchange of confidential information between the EIU Counseling Clinic and the selected parties. Only information necessary to support your care will be shared. You have the right to inspect, revoke, or limit this authorization at any time in writing.  

Privacy Practices/Consent to Treatment 

Students will complete this form prior to starting services at the EIU Counseling Clinic and at the beginning of each semester. This form will be completed using the Electronic Health Record. 

No Show Dispute Form

We understand that unexpected situations can arise. If you missed a scheduled appointment and believe you were incorrectly charged a No-Show Fee, you may use this form to request a review. Please provide as much detail as possible, including the date of the appointment and the reason for the missed session. Note: Submission of this form does not guarantee removal of the fee.

Medical Withdrawal 

More information can be found at the Withdrawal website

Grievance Form

If you have any concerns or issues, we strongly encourage you to first discuss them directly with your counselor. Often, concerns can be addressed informally through open communication. If the issue remains unresolved or you feel uncomfortable doing so, please feel free to reach out to the Associate Director to discuss the matter further. If you prefer to file a formal grievance, you have the right to do so by completing this form.