Information for Past Clients

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Please indicate if you would like to receive your entire record or part(s) of it. *

The entire record would include progress notes for each therapy session, diagnosis, treatment plan, billing records, and intake documents.

I would like to receive my entire record.

I would like to receive part(s) of my record.

Please select which part(s) of your record you would like to receive: *

Select all that apply.

Treatment Summary (includes summary of the assessment, diagnosis, treatment provided, and date range of services)

Billing Records

Any Release of Information forms you signed

Any Intake Documents you completed

Other (please specify below)

n/a (I requested the entire record)

Please note that the record may be provided within 30 days from the date of this request. You will receive an email notification when your records have been sent via your Client Portal. *

I understand