EmailMeForm
Student Mental Health Emergency
Contact Release Form
State law 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. Should you choose to designate someone, it can be anyone over the age of 18 (parent, relative, sibling, family friend, etc.).
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 form below:
Your Name
*
First
Last
Student ID Number
*
Today's Date
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MM
/
DD
/
YYYY
Please check a box below to indicate the action you would like to take. I do understand that I can change my mind at any time and resubmit this form in the future. I also understand that under certain circumstances, as allowed or required by law, certain college officials may contact my parents or others in the event of an emergency to protect my life or the lives of others without my express written consent.)
*
I would like to designate one individual as a contact in the event that I am evaluated by a BHC qualified examiner.
I have previously identified a contact, but would now like to change to a new contact.
I have previously identified a contact, and would like to decline a name of contact (you will no longer have a contact on file).
I DO NOT want to designate a person as a contact in the event that I am evaluated by a BHC qualified examiner.
By checking the below box, I would like Black Hawk College to contact the following person in the event that I am evaluated by a BHC qualified examiner as being a clear danger to myself or to others. I also understand that I can change this designation, or decline to name a contact at any time by completing this form again.
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Yes, the college may contact the following person.
Designated Person's name
*
First
Last
Designated Person's address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Designated Person's Phone
*
###
-
###
-
####
Designated Person's Email
*
Designated Person's Relationship to You
*
