Student Optional Disclosure

Disclosure of Private Mental Health Information Reporting

The State of Illinois Public Act 099-0278 grants students the opportunity to designate a contact person 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.).

Please understand that under certain circumstances as allowed and/or required by law, university officials may contact family members or others in the event of an emergency without your expressed written consent. You have the right as a student to withdraw or revoke your Mental Health Emergency Contact authorization by utilizing the form below.

Questions about designating or changing a Mental Health Emergency Contact should be directed to Cindy Danzell at cdanzell@nl.edu.

Submit Your Disclosure of Private Mental Health Information Reporting Form