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PERMISSION TO CONTACT FORM

When you sign this consent for it gives the Center for Survivors permission to have someone contact you to schedule an appointment. We will do everything we can to ensure your safety and honor your privacy as we try to contact you. The MSU Center for Survivors is a Confidential Resource at MSU.

We want you to be safe, get support and know your options and rights.


The MSU Center for Survivors offers FREE Counseling, Support Groups, and Advocacy.


Please sign and return the form below to the person who gave it to you or send it to the address or fax below and someone from the Center for Survivors will contact you soon.


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The information may be shared: in person by phone by fax by e-mail*


I understand that email is not confidential and can be intercepted and read by other people.


I authorize the release of the following information to the MSU Center for Survivors: My Name: _ _

Phone:

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E-mail:


Gender Pronoun (optional): I am available (days/times):


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Signature:

Date:


MSU Center for Survivors

556 East Circle Drive

207 Student Services Building East Lansing, MI 48824 Phone: 517-355-3551

Crisis Line: 517-372-6666

FAX: (517) 353-8912