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Counseling and Psychological Services

CAPS Release of Information Form

Instructions for use of CAPS Release of Information Form:

  1. Your medical record at Counseling and Psychological Services is confidential though it may be released by you to a second party with your written consent. To do so CAPS needs to receive a signed copy of our Release of Information Form (under FAQ’s see – Are CAPS services confidential? – Legally Authorized Exceptions).

  2. Click here for a copy of the CAPS Release of Information Form

  3. At the top of the page enter your name and date of birth. Select from the available options the content you want released or after "Other" describe what you want released.

  4. Select whether you want the information released "from" CAPS", "to CAPS" or exchanged between CAPS and a third-party.

  5. Also select and initial the lines which identify release via e-mail or fax. Leave blank if not applicable.

  6. Identify the party whom you want the information released to and include appropriate information such as address, phone, e-mail or fax.

  7. Select why you want the information released or, after "Other" enter your own description.

  8. Identify what dates of contact with CAPS the release pertains to.

  9. Sign, provide your student ID# and the date at the bottom of the page.  You may fax the document to: 434-243-6693 or mail to:

Counseling and Psychological Services
Department of Student Health
PO Box 800760
Charlottesville, VA 22908-0760

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