Client Form For Requesting Records

CLIENT RECORDS REQUEST PACKET

Last Revised: July 2020
CLIENT GUIDE FOR REQUESTING RECORDS
Former therapy clients have the right to request access to their psychotherapy records. If you would like to do so, please complete the following steps. Please read all instructions carefully and fill out forms in their entirety. Any missing required information may slow down our processing time and/or ability to fulfill the request.
Instructions:
1. Fill out the Request for Records form as thoroughly as possible.
  - Please note that we are unable to respond to any requests that do not include a working telephone number where we can reach you.
  - There is a chance we will be calling you from a blocked number. Please make sure your phone is able to receive blocked calls.
2. To ensure confidentiality and to verify your identity, we request that you include a copy of your government-issued photo ID with your request.
  - You can upload your file at the end of this form.
3. If you are requesting that your records be sent to a third party, you will also need to fill out an Authorization for Release of Confidential Information (included in this form) in order to legally authorize us to release your records.
  - Please be sure to include what information you want shared and the reason you would like this information shared.
Important information:
- Please be advised that this is the process for requesting an individual client record. If the client was seen as part of a couple or a family, each member of the family who participated in treatment will need to follow the same steps.
- To adhere to confidentiality standards, we are unable to respond to any requests via email.
- Once we have received the request, someone from our office will call you at the number provided to acknowledge receipt of the request and ask any necessary follow up questions.

Authorization for Release of Confidential Information
I, {fullName}, hereby authorize the Office of Clinical Training at John F. Kennedy University to release confidential information regarding my treatment with the following person or entity:
Name of Agency: *
Specific Person/Department:
Position/Relationship:
Agency Mailing Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Agency Phone Number:

Area Code Phone Number
Agency Fax Number:

Area Code Phone Number
I would like to access and/or have sent (check all that apply): *

Dates of Treatment Diagnosis Treatment Plan Progress Notes Clinical Test Results Entire Psychotherapy Record Other
I authorize the release of the information described above for the following purpose(s): *
Be as specific as possible, e.g. to verify my treatment, help me obtain benefits)
The recipient may use the information described above solely for the following purpose(s): *
Be as specific as possible, e.g. to determine my eligibility for their program
I understand the following:
I have a right to receive a copy of this authorization. *
Please Initial
I may withdraw or modify my consent to this release at any time. *
Please Initial
Any cancellation or modification of this authorization must be made in writing. *
Please Initial
This exchange expires on: *

Month Day Year
Date
Client Name *

First Name Last Name
Client Signature *

Clear
Date Signed: *

Month Day Year
Date
Name of Parent/Authorized Representative (if applicable)

First Name Last Name
Signature of Parent/Authorized Representative (if applicable)

Clear
Date of Signature

Month Day Year
Date
If signed by other than the Client, please indicate the relationship between the Client and the Authorized Representative:
Should be Empty:

CLIENT RECORDS REQUEST PACKET

CLIENT GUIDE FOR REQUESTING RECORDS

REQUEST FOR RECORDS FORM

Authorization for Release of Confidential Information