Loyola University Chicago

Wellness Center

Student OPTIONAL Disclosure of Private Mental Health Information

In compliance with the State of Illinois Student Optional Disclosure of Private Mental Health Act, all incoming students of Loyola University Chicago have the opportunity identify any adult individual/s that you would wish to be notified in the event that a qualified mental health provider employed by the university refers you for inpatient psychiatric hospital care if it is determined  you might pose a danger to yourself or to others.  

Completion and submission of this form is optionalIf you do wish to designate such a contact person, please print out this form (Disclosure of Private Mental Health Information) and then mail the completed form to:

Emergency MH Contact
The Wellness Center
Loyola University Chicago
6439 N Sheridan Rd., Ste.  310
Chicago, Il 60626

Alternatively, you may fax the form to:   

Attn.: Emergency MH Contact
The Wellness Center
Loyola University Chicago
(773) 508-2242