OKLAHOMA STATE UNIVERSITY – OKLAHOMA CITY
SOCIAL SERVICES DEPARTMENT
ALCOHOL AND SUBSTANCE ABUSE COUNSELING
I, ________________________________ of__________________________________
Student’s Name Address
Name of Site Supervisor AND Agency Name
to disclose to ___________________________________________________________
OSU-OKC Course Instructor’s Name
information regarding perceptions of my performance as a practicum student at aforesaid treatment organization.
I understand that records about me 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 to ethical and legal standards should not be re-disclosed without written consent of the student.