Psychotherapy Notes Access Request Form

Psychotherapy Notes Access Request Form
Request access to psychotherapy notes by completing the information below. All requests are handled securely and confidentially.
Your Full Name
First NameLast Name
Your Email Address
example@example.com
Your Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you the patient whose notes are being requested?
Patient's Full Name (if different from requester)
First NameLast Name
Your relationship to the patient (if not self)
Reason for requesting psychotherapy notes
Please specify the date range or specific notes you wish to access
Preferred delivery method
Mailing Address (if requesting postal mail)
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Upload supporting documentation (e.g., proof of authority, ID)
Cancelof
Signature of requester (type or draw your signature)
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Date of request
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: