5. Client Form For Requesting Records - 6/23 Logo

  • CLIENT RECORDS REQUEST

    Last Revised: June 2023

  • Current and former therapy clients have the right to request access to their psychotherapy or psychological assessment records. Please read all instructions carefully and fill out all fields as thoroughly and accurately as possible. Any missing or inaccurate information may slow down our processing time and/or ability to fulfill the request.

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    Important information:

     

    If more than one person was a part of therapy, EACH individual will need to complete this request.

     

    To adhere to confidentiality standards, we are unable to respond to any requests via email. Therefore, we require a working telephone number to reach you. 

    • We may call from a blocked number. Please make sure your phone is able to received blocked calls.
    • Make sure the voicemail on your phone is set up and is not full, so we can leave a message as needed. 

    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 follow-up questions needed to process your request.

  • REQUEST FOR RECORDS FORM

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  • Please note: If more than one person is/was involved in the therapy, EACH individual will need to fill out this request.

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  • In order for us to share any confidential information with a third party, you will be asked to fill out an Authorization to Release Confidential Information on the next page. 

  • Date and time of pick-up must be pre-arranged. Please note that in-person pick-up may not be possible for all records and is subject to personnel availability. 


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  • Authorization for Release of Confidential Information

  • hereby authorize the Office of Professional Training in the JFK School of Psychology and Social Sciences at National University to release confidential information regarding

  •  with the following person or entity:

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  • Client Rights

    • I have the right to receive a copy of this authorization.
    • I may revoke or modify this authorization at any time.
    • Any cancellation or modification of this authorization must be made in writing.
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