Mental Disclosure

Click here to complete the disclosure form.

In accordance with the Student Optional Disclosure of Private Mental Health Act (IGP 59.1), Chicago State University is providing students the opportunity to authorize in writing the disclosure of certain private mental health information to a designated person of your choosing.

This Act states that an institution of higher learning may disclose mental health information if a physician, clinical psychologist, or qualified examiner, makes a determination that the student poses a clear danger to himself, herself or others to protect the student or other person against a clear, imminent risk of serious physical or mental injury or disease or death being inflicted upon the person or by the student on himself, herself, or another. The physician, clinical psychologist, or qualified examiner shall, as soon as practicable, but in no more than 24 hours after making the determination under this section, attempt to contact the designated person and notify the designated person that the physician, clinical psychologist, or qualified examiner has made a determination that the student poses a clear, imminent danger to himself, herself, or others.

If you desire to designate a person that would receive certain private mental health information in such a situation, please complete the form above and return it to the Office of the Registrar. You can also email the form to CSU-Registrar@csu.edu , in the subject line please include Mental Disclosure.  The form will allow you to affirmatively authorize, or decline to authorize, the disclosure of the information.