Records Request Form "*" indicates required fields Δ Client InformationClient Full Name* First Last Client Email* Client Phone Number*Client Date of Birth* Month Day Year Requestor InformationRequestor Full Name* First Last Relationship to Client*Organization (if applicable)Email* Phone*Records Requested* Full Medical Record Progress Notes Treatment Plan Discharge Summary Billing Records Other Delivery Method* Secure Email Fax Number Mail Pick Up In Office What records, if otherSecure Email Fax NumberMailing Address Street Address Address Line 2 City STAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code AuthorizationAuthorizer Full Name* First Last Today's Date* Month Day Year Time of the Request* Hours : Minutes AM PM AM/PM Send me a copy of my responses* Yes No Request An Appointment "*" indicates required fields Δ First & Last Name** First & Last Name* Email** Phone**Mental Health Insurance?*Mental Health Coverage? (Yes, No, or Self Pay)YesNoSelf-PayInsurance ProviderReferred ByChoose a Therapist*Choose a TherapistKali ScheschukSteve LongAimee BentleyJoanna EdkleyMelinda GoudeauMindy ClarksonMeagan HamptomJane PalaciosCrystal BowmanPlease assign me to a therapistAdditional Appointment Information
