Records & Additional Services Request
Client Name
*
First Name
Last Name
Your Name
*
First Name
Last Name
Relationship to Client
N/A if you are requesting your own records.
Records Fee Schedule
$20 processing fee + $0.65 per page for first 30 pages, $0.50 per page thereafter.
Which records are you requesting:
Assessment
Treatment Plan
Progress Notes
Addition services not covered by insurance:
Written Affidavit / Paperwork Request from Therapist: $90 per document
Phone calls or meetings with legal representatives, guardian ad litem, DSS, CPS, etc: $90 per hour
Court appearance: $350 (up to 4 hours, $90 per hour therafter) ***Courthouse must be located within 20 mile radius of the therapist's office***
If you are an attorney or guardian of the Client, please provide evidence of representation:
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BY SIGNING BELOW You agree to the Fee Schedule above. Your signature below allows us to process the existing credit/debit card on file (checks are required for clients under representation).
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