Records Request Form

Home / Contact Us / Records Request Form

* Indicates required fields

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

Client'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 Client*

File Upload*

Please upload signed 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.

Important

To request records from Crossnore, you’ll need to fill out this form.

This is to be used only to request records from Crossnore Communities for Children.

Although Marjorie Williams Academy and Anderson Academy are located on Crossnore’s campuses, they are not part of Crossnore Communities for Children and therefore, If you need records from Marjorie Williams Academy or Anderson Academy, please contact them directly. Marjorie Williams Academy can be reached at at (828) 733-5241 or by fax at (828) 737-7915 and Anderson Academy can be reached at (336) 703-9292 or info@andersonacademyws.org.