I understand that such disclosure will be limited to the following specific types of information:
1. Information concerning general progress while in Access 2 Recovery programs;
2. Counselor’s reports of attendance, participation and prognosis;
3. Information contained in written records submitted by myself;
4. General demographic and academic information;
5. Indications of active alcohol or other drug use;
6. Admission and discharge dates including associated reports
7. Other:___________________________________________________________
I understand this consent will remain in effect for two (2) years from the date of signature below.