Attachment III

REQUEST FOR AUTHORIZATION TO EXCHANGE INFORMATION

(Date)

To: (Student)

Because of (describe incident or behavior), Texas State is concerned about your emotional health and your ability to function effectively within an academic or residence hall community. Therefore, as a condition for you to continue as a student or to live in a residence hall, we require that you:

· complete a psychological evaluation;

· share with us the results of that evaluation; and

· keep us informed of your progress.

In order for us to obtain information regarding your evaluation, please sign the attached Authorization to Exchange Information.

Your signature authorizes Texas State’s Dean of Students, Student Health Center, and Counseling Center to exchange relevant information regarding your evaluation. This information will be used only by Texas State employees within these departments who have a legitimate need to know this information.

Your signature on the authorization will not jeopardize the accuracy or confidentiality of your Texas State records. Texas State’s officials will not disclose your records without authorization. This authorization applies only to those items indicated. You may refuse to sign this authorization, but university officials may consider your refusal in determining your eligibility to continue as a student.

Sincerely,

Dr. John H. Garrison, Dean of Students

Dr. Greg Snodgrass

Director, Counseling Center

Dr. Emilio Carranco

Director, Student Health Center