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914 355 2440
Home
Services
Individual Therapy
Couples Therapy
Teen Therapy
Family Counseling
Child Therapy
Anger Management
Online & In-Person Therapy
Insurance
Current Clients
Patient Portal
Billing & Insurance help
Medical Record Request
Provider Referrals
Resources
Therapists
Our Mission
Leadership Team
Career
Blog
FAQ
Links
Privacy Policy / HIPAA
Contact Us
Menu
Medical Record Request Form – Parent/Guardian
Home
Medical Record Request Form – Parent/Guardian
Medical Record Request Form – Parent/Guardian
Medical Record Request Form – Parent/Guardian
Medical Record Request Form - Parent/Guardian
Request for Letters or Forms on Behalf of a Minor
Parent/Guardian First Name
Parent/Guardian Last Name
Relationship to Client
Parent
Guardian
Other
Parent/Guardian Phone
Parent/Guardian Email
Authority Type (check one)
Birth/Adoptive Parent
Legal Guardian
DCF / ACS Custody
Other
Minor’s Information
Minor’s First Name
Minor’s Last Name
Minor’s Date Of Birth
Type of Document Requested
Treatment Status Letter
Narrative Summary Letter
School Form (504/IEP support, counselor communication, etc.)
Camp Form
Accommodation Letter (educational setting)
Other
All Records
Ways to Complete Your Records Release Form
Download, Complete, and Upload
Request the Form via Your Client Portal
Complete the Form in Person
Click Here To
Download The HIPAA Form
HIPAA Authorization
Attach signed HIPAA Authorization for the release of the requested information.
Processing & Fees Notice:
Standard turnaround: 7–10 business days
Fees may apply depending on complexity or external requirements
Requests may be delayed if incomplete or missing authorization
Legal Disclosures:
You may revoke this authorization in writing at any time. Released information may be re-disclosed by the recipient and may no longer be protected by HIPAA.
Only the minimum necessary information will be released in accordance with HIPAA.
Acknowledgements
I understand that verification of legal authority may be required, that certain adolescent therapy records are confidential by law, that standard processing time is 7–10 business days, and that my authorization is voluntary and may be revoked at any time in writing.
