Records Request Form

* Indicates required fields

Consumer's Name (at the time of services)*

Consumer's Date of Birth*

Requestor's Name*

Requestor's Mailing Address (if asking records to be mailed)

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

Requestor's Phone Number*

Requestor's Fax Number

Requestor's Email

Requestor's Relationship to Consumer*

File Upload*

Please upload Release of Information Consent or Proof of Identity (birth certificate or driver's license/state ID) for your request to be completed.

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 50 MB.

In the space below, describe the purpose of your request.*

Request Type*

Documents Requested*

Clinical Assessment

Psychiatry Assessment

Discharge Summary

Most Recent Clinical Service Plan or Person-Centered Plan (PCP)

Clinical Treatment Update

Residential Services Reports

Other - please specify below

If you marked Other above, please specify what records you are requesting.