Well BH- Record Request Form

Record Request Form

Well Behavioral Health, LLC
Client's Name*
Client's DOB*
Email*
example@example.com
I am requesting a copy of my mental health record:*

My full mental health recordA specific portion of record as indicated below:
Specific portion of record requested.
Please include date ranges
Your record will be available within 5 business days after you have submitted this request, and will be available for download on the client portal.
Signature of patient (or parent / guardian)*
Date*

MonthDayYear
Should be Empty: