Policies & Forms

Student Mental Health Emergency Contact Release Form

In accordance with the Student Optional Disclosure of Private Mental Health Act (IGP 59.1), Black Hawk College is providing students the opportunity to authorize, in writing, the disclosure of certain private mental health information to a designated person of your choosing.

This Act states that an institution of higher learning may disclose mental health information if a qualified examiner makes a determination that the student poses a clear danger to himself, herself or others to protect the student or other person against a clear, imminent risk of serious physical or mental injury or disease or death being inflicted upon the person or by the student on himself, herself, or another. The qualified examiner shall, as soon as practicable, but in no more than 24 hours after making the determination under this section, attempt to contact the designated person and notify the designated person that the qualified examiner has made a determination that the student poses a clear, imminent danger to himself, herself, or others.

If you desire to designate a person that would receive certain private mental health information in such a situation, complete the form here and click “submit.” The form will allow you to affirmatively authorize, or decline to authorize, the disclosure of the information.

The Student Optional Disclosure of Private Mental Health Information Act in the state of Illinois provides you with the opportunity to designate an adult whom you would like us to contact in the event that you experience a mental health emergency that puts you or others at risk for serious injury or death. You are not required to designate a contact. If you would like to designate an Emergency Mental Health Contact please fill out the online form located here: www.bhc.edu/sod

Last updated 12/15/2016