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Release of Information

Authorization for Release of Information Form: In order to allow Cook Counseling Center to release information that you would like to be shared with others, please complete and sign this form, and return to your provider or to the Cook Counseling Center reception desk.

Academic Relief Forms

Application Packet for Academic Relief:  This packet contains two forms. A completed application packet must include both: 1) Academic Relief Request Form completed by the student, and 2) Dean's Academic Advising Form signed by the Associate Dean of the student's academic college. If the applicant is an international student, the Advising Form should also be signed by staff at Cranwell International Center. If the applicant is a Graduate International student, the advising form should be signed by  an international advisor at the Graduate School.

If a student is submitting supporting information from an off-campus provider, an Outside Provider Documentation Form to Support Academic Relief Application may also be submitted with the application packet. 

When a student is preparing to return to Virginia Tech following a medical withdrawal for mental health reasons, a Provider Form for Re-enrollment must be completed by their counseling or psychiatric provider and submitted to Cook Counseling Center in order to authorize the removal of the registration hold on the student's account.

Outside Provider Forms for Referral to CCC

If an outside provider wishes to refer a VT student to the Cook Counseling Center for counseling or psychiatric services, they are requested to submit the Outside Provider Referral Forms packet.