PRACTICUM RELEASE

To be filled out with OSU-OKC Course Instructor

I, _________________________________ of _________________________________

Student’s Name Address

authorize ______________________________________________________________

OSU-OKC Instructor

to disclose to ___________________________________________________________

Name of Site Supervisor AND Facility

information of record regarding my academic and professional preparation for purpose of facilitating my practicum experience at aforesaid substance abuse counseling agency.

I understand that my records are protected under Federal and specific State confidentiality laws and regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance and that, in any event, this consent expires automatically ten (10) days following completion of my practicum assignment.

I further acknowledge that this consent is given of my own free will.

Executed this ___________ day of _____________, 20____.

___________________________________________________ _______________

Signature of Student Date

___________________________________________________ _______________

Signature of Witness Date

This information is confidential and according the legal and ethical standards should not be re-disclosed without the written consent of the student.