This government document is issued by Lewis-Clark State College for use in Idaho
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https://www.google.com/url?client=internal-element-cse&cx=005940473117795338789:bg8klueq83a&q=https://www.lcsc.edu/media/5870/mental-health-verification-form-fillable.pdf&sa=U&ved=2ahUKEwiM-o-tu_2GAxWN8gIHHRlgAs44UBAWegQICBAB&usg=AOvVaw2f-w-mxEDMJXVJ7fWwVyOz&fexp=72519171,72519168