Records Request

AUTHORIZATION to RELEASE INFORMATION

"*" indicates required fields

Client Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Phone*

Email*

Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Fax

Service Start Date*

Service End Date

Check All That Apply*

Progress Notes

Group Notes

One-to-One Notes

Discharge Summary

Functional Assessments

Diagnostic Assessment

Treatment Plan

Purpose of release*

Digital Signature*

Please type Client name or Legal Guardian/Authorized Person here.

Relationship to Patient

Today's Date

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