Authorization to Release Mental Health Information (ROI)

Use this form to request mental health information from previous visits.

Instructions:

1. Open and download the form as a PDF.
2. Complete all requested information in the PDF.
3. Initial each required item on the form.

4. Enter specific dates or a defined date range for the records you are requesting (for example, May 1, 2026 to June 30, 2026).

5. Do not use vague terms such as “present” or “graduation” in place of specific dates.

6. If you include an expiration date, it must be a specific date and allow at least 15 days for processing (for example, June 7, 2026).

7. Email the completed form to counseling@calpoly.edu.

No Show/Late Cancellation

Use this form to request cancellation of a no show or late cancellation fee due to extenuating circumstances or an error.

Instructions:

1. Open and download the form as a PDF.
2. Complete all requested information in the PDF.
3. Email the completed form to counseling@calpoly.edu.

Change of Clinician

Use this form to request a change of mental health provider.

Instructions:

1. Open and download the form as a PDF.
2. Complete all requested information in the PDF.
3. Email the completed form to rshurson@calpoly.edu.

Request to Decline Disclosure

Use this form to request that specific protected mental health information not be disclosed through the Cal Poly Health & Counseling Portal.

Instructions:

1. Open and download the form as a PDF.
2. Complete all requested information in the PDF.
3. Email the completed form to counseling@calpoly.edu.