OKLAHOMA STATE UNIVERSITY – OKLAHOMA CITY
SOCIAL SERVICES DEPARTMENT
ALCOHOL AND SUBSTANCE ABUSE COUNSELING
I, _________________________________ of _________________________________
Student’s Name Address
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.