General Forms

General Forms

Authorization to release or exchange mental health information form

This form is used to release your protected health information as required by federal and state privacy laws. Your authorization allows the Counseling Center to release your protected health information to a person or organization that you choose. Please note this form will need to be handed in in person, or sent directly from another provider.

Opt Out of Accessing Counseling Center Records on WHCS Portal UCI

UCI Counseling Center is legally required to make your relevant clinical notes available to you on the Wellness, Health and Counseling Services (WH&CS) student portal, except under certain conditions. One of the conditions is when you choose to opt out of this access is you may choose to opt out of having portal access to particular notes or all of your Counseling Center notes by completing this form. To opt out, download the pdf below and turn the form into the Counseling Center front desk or your therapist.

2022-2023 SHIP Mental Health Referral Form

If you are a undergraduate or graduate student with SHIP insurance and are looking for or being referred off campus for mental health services you will need to complete a referral request. Please find  steps to complete the SHIP Mental Health Referral Form below:

Once you have an appointment scheduled, you need to contact the UCI Student Health Center Insurance Office to request a referral (also known as an authorization) to the provider you’ve selected.

You can call them at 949-824-2388 or you send a referral request securely via the patient portal. 

• Select “Messages” on the left sidebar > select “New Message” > select “SHC – Insurance Department: Referral Request and Other General Inquires” > select “SHC – Referral Request”. Once the fields are populated click “Submit.” Please allow 1-2 business days for referral processing.
• You will need to provide them with the name, address, phone number, and fax number (if they have one) of the therapist you are going to see. The Insurance Office will then send a referral to the therapist on your behalf. 

**Please note that while most therapists and group practices require the authorization after an appointment is made, some group practices require the authorization in advance of scheduling an appointment. In this case you can use the name of the group practice.**

Disability Services Center Documentation Information

If you are working with Disability Services Center and need a Counseling Center provider to fill out the DSC Disability Vertification Form please go to this website to find the form:  https://dsc.uci.edu/documentation/