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If you wish to have us share your clinical information with others, please complete the Authorization below. If you complete it in paper form, you will need to turn it into our front desk or fax it (949) 824-6586. You may also call our front desk at (949) 824-6457 for an electronic version of the form.
The UCI Counseling Center is legally required to make your relevant clinical notes available to you on the My Student Chart portal with limited exceptions. One exception is when you choose to opt out of this access to particular notes or all of your Counseling Center notes by completing this form. If you complete it in paper form, you will need to turn it into our front desk or fax it (949) 824-6586. You may also call our front desk at (949) 824-6457 for an electronic version of the form.
If you are working with Disability Services Center (DSC) and need a Counseling Center provider to fill out a DSC Disability Verification Form, please go to the Disability Services Center website to find the relevant form.