Records Request Form

We’re happy to help with your records request. Please complete the form below to let us know which records you are requesting. This form is securely submitted through Hushmail to help protect your private information. Once processed, all records will be provided directly to you through your secure SimplePractice Client Portal. Though we aim to provide these records as soon as reasonably possible, please allow up to 15 calendar days for your request to be processed.

Client Full Name

Client Date of Birth

Date of Request

What records are you requesting?

Attendance Letter

Treatment Summary

Diagnosis/Treatment Plan

Intake Assessment

Progress Notes

Other

Purpose of Request

Personal use

Third Party Request

Name of Person Completing this Form

Relationship to Client

By submitting this form, I am requesting the records identified above. Client understands and agrees providers have 15 calendar days to provide record request.

Your information will be encrypted.