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Release and/or Exchange of Information
The Confidential Victim Advocate at Fresno State provides confidential crisis intervention, advocacy, and support services to students, staff and faculty members who have experienced sexual and/or dating/domestic violence. The Victim Advocate will not disclose any personally identifying information without your written permission except in the following cases (1) self-harm (2) harm to others (3) court ordered to release information.
The following form will dictate what type of information you would like released/shared and to whom you would like it released to or shared with. You have the right to cancel this consent form at any time through written notification.
Person authorizing the release
Information to be released
(select all options that apply. You can share as much or as little information as you would like)
Sought services from the Victim Advocate
Victim/survivor of sexual violence
Victim/survivor of dating/domestic violence
Victim/survivor of stalking
Purpose for the release of information (
select all choices that apply
ou can choose as many or as few as you would like)
Accommodation facilitation (housing)
Accommodation facilitation (academic)
Accommodation facilitation (no contact/stay away order)
Accommodation facilitation (transportation)
Documentation of Incident/Assault
Person/Agency to whom the information is to be released
(you can choose as many or as few options as you would like
Counseling and Psychological Services
Dean of Students
Title IX Coordinator
Administrator/ Staff Member
Student Conduct Administrator
Rape Counseling Services
Marjaree Mason Center
Method of exchanging information
(select all that apply)
I understand that i have the right to change this consent at any time but must notify the victim advocate in writing to cancel or change this release.
Please Initial the box below
Signature of person authorizing the release
Date of release of information
Victim Advocate Signature and Date
I revoke any release of information consent given prior to this date.
Please sign/write your name and enter the date you would like the consent to release revoked in the text box below.
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