Letter/Record Request Form

"*" indicates required fields

Full Name*

DOB:*

MM slash DD slash YYYY

Phone*

Address*

City, State, Zip*

Email*

Preferred Contact*

Phone

Email

Other

Client Status*

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)*

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?*

Yes

no

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

Diagnosis

Excused Absence

Work Accommodation

Education Accomodation

Emotional Support Animal (ESA)

Other

Provide Reason For Requesting Records/Letter?*

Provider/Company Must Upload A Client Signed Authorization

Max. file size: 64 MB.

Phone

This field is for validation purposes and should be left unchanged.