Optional Disclosure Authorization

The Illinois Student Optional Disclosure of Private Mental Health Act (PA 099-0278) requires that institutions of higher education, including community colleges, provide to all students the opportunity to authorize the College in writing to disclose certain private mental health information to a person designated by the student.

Who can I identify as a designated person?

A student may designate a parent, guardian, or other person over the age of 18 to receive private mental health information from the College.

What information will be disclosed and under what circumstances?

The College may disclose a student’s mental health information to the designated person if a qualified examiner, who is employed by the college, determines that the student poses a clear danger to himself, herself, or others. The purpose of the disclosure in such case is to protect the student or other person against a clear, imminent risk that the student may inflict serious physical or mental injury, disease or death on himself, herself, or another individual. The qualified examiner is required to disclose this information to the designated person as soon as possible, but no more than 24 hours after making the determination that the student poses such a danger.

Please note: The College does not currently employ any individuals who serve as qualified examiners and who are in a position to make the mental health determination above. Therefore, the College cannot assure that by identifying a designated person, the College will be able to disclose the student’s condition to that designated person.

1. Student Information

   1. First Name
   2. MI
   3. Last Name
   4. Student ID @XXXXXXXX
   5. Street Address
   6. City
   7. State IL
   8. Zip
   9. Phone
   10. Date of Birth MM/DD/YYYY
2. Designated Individual Contact Information

   1. Name
   2. Relationship to Student
   3. Street Address
   4. City
   5. State IL
   6. Zip
   7. Preferred Phone
   8. Alternate Phone
3. Authorization

   1. Yes, I authorize disclosure of my mental health information as described above to the individual I have identified on this form, which shall be valid unless and until I revoke it by notifying the College in writing that I am withdrawing this authorization.
   2. No, I do not authorize the College to disclose my private mental health information as described above to a designated person. If I change my mind, I understand I must submit a new form designating such an individual and authorizing the College to disclose my mental health information to that individual under the circumstances described above. I also understand that under certain circumstances as allowed and/or required by law, College officials may contact my parents, family members or others in the event of an emergency without my consent.