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Letter/Record Request Form

Full Name(Required) DOB:(Required) MM slash DD slash YYYY Address(Required) Phone(Required)Email(Required)

Preferred Contact(Required)

Phone Email Other

Client Status(Required)

Current Client Previous Client Provider/Company Requesting for the Client

If Provider/Company, State Your Affiliation to Client Affiliation to Client

Which Records Are You Requesting? (Check All That Apply)(Required)

Diagnostic Evaluation Treatment Plan Specific Session Notes All Session Notes Assessments Questionairres Other

If you need specific notes, please provide the dates of the notes you're requesting.

Do You Need A Letter From Your Clinician?(Required)

Yes no

If Yes, Select Letter type below. (Check All That Apply)(Required)

Diagnosis Excused Absence Work Accommodation Education Accomodation Emotional Support Animal (ESA) Other

Provide Reason For Requesting Records/​Letter?(Required) Provider/Company Must Upload A Client Signed AuthorizationMax. file size: 128 MB.NameThis field is for validation purposes and should be left unchanged.