Forms

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.

Please be ready to show your ID when submitting. Forms can also be faxed to 540-231-2104, but must contain a copy of your ID for verification.

Academic Relief Forms

Undergraduate and graduate students facing chronic and significant mental illness that compromises their ability to complete academic requirements (attending classes, completing assignments) for an extended period of the semester may seek Academic Relief.

Undergraduate Students: Information on the university’s Academic Relief policy can be found in the Undergraduate Catalog. Students may apply for Academic Relief through the online portal.

Graduate Students: Information on the Graduate School’s Academic Relief policy can be found on the Graduate School forms page under “Enrollment/Registration.”

Cook Counseling providers can supply supporting documentation for students who have been in on-going care with Cook Counseling Center prior to applying for Academic Relief. Please note: On-going care is defined by attending individual counseling, group counseling, and/or psychiatric appointments focused on meeting specific personalized treatment goals. Attending a Cook Connect (triage) and/or Crisis Consultation Appointment does not meet criteria for established on-going care.

Outside Provider Forms for Referral to Cook Counseling Center

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.