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OKLAHOMA STATE UNIVERSITY – OKLAHOMA CITY

SOCIAL SERVICES DEPARTMENT

ALCOHOL AND SUBSTANCE ABUSE COUNSELING

 

PRACTICUM RELEASE

To be filled out with SITE SUPERVISOR

 

 

 

I, ________________________________ of__________________________________

            Student’s Name                                                                      Address

 

authorize ______________________________________________________________

                        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.