Letter/Record Request Form

Immediate appointments available online & in-person

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We have appointments available online and in-person

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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 ClientIf 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

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.

LOCATIONS

Integrative Behavioral Health, LLC

120 Sister Pierre Dr., #205
Townson, Maryland 21204

443-288-0098

2519 Maryland Ave. Ste. 100
Baltimore, MD 21218

443-288-0098

BUSINESS HOURS

MONDAY:

8:00 AM - 8:00 PM

TUESDAY:

8:00 AM - 8:00 PM

WEDNESDAY:

8:00 AM - 8:00 PM

THURSDAY:

8:00 AM - 8:00 PM

FRIDAY:

8:00 AM - 8:00 PM

SATURDAY:

8:00 AM - 8:00 PM

SUNDAY:

CLOSED

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