Records Request Form

If you need records from Marjorie Williams Academy, please contact the Academy at (828) 733-5241 or by fax at (828) 737-7915.

Consumer's Name (at the time of services)*
Consumer's Date of Birth*
MM slash DD slash YYYY
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.
Crossnore does not release any 3rd Party documents (documents obtained from external agencies during the course of services) or Psychotherapy Notes.