Upon submitting this form, we will contact you immediately if possible, or within 24 business hours. 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 ClientWhich 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.