Authorization to Release of Medical Records

All information is considered confidential and will not be released without the patient’s written consent or a signed court order.  Counseling and Psychological Services retains medical records for 7 years past the last date on which the service was given.

Your medical records may include history, diagnoses, and/or treatment of drug or alcohol abuse, mental illness, or communicable disease, including Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS).

The charge for this service is $1.00 per page for the first 25 pages. After the first 25 pages the fee is 50 cents per page payable by credit card or charge to your student account.

To request copies of your records

Send or bring a completed Authorization to Release Mental Health Records Form and payment of applicable fees.

  • IN PERSON
    Submit an Authorization for Release of Mental Health Records Form with applicable fees and a picture ID to the Counseling and Psychological Service front desk. Cash, checks, Visa, Discover or MasterCard accepted.
  • MAILED REQUESTS Send a completed Authorization for Release of Mental Health Records Form, legible copy of your driver’s license and applicable fees to Counseling and Psychological Services. Checks accepted.
  • FAX REQUESTS
    Fax a completed Authorization for Release of Mental Health Records Form and a legible copy of your driver’s license to Counseling and Psychological Services at 713-743-5446.  Contact Counseling and Psychological Services at 713-743-5454 after faxing your request to render payment of applicable fees by Visa, Discover or MasterCard.

Counseling and Psychological Services will respond to complete/authorized request for mental health records within approximately seven (7) to fifteen (15) days after the receipt of a valid request and applicable fees.  Records may be sent by mail or held for pick-up.  Upon request Counseling and Psychological Services will fax records.


Please read the instructions above before completing the authorization form.

Authorization Form