Authorization For Release Of Psychological / Counseling Records
A form letter to use to Authorization For Release Of Psychological / Counseling Records
Use this Psychological / Counseling Records Release form to allow another party (typically your ex-spouse) to authorize the release of his or her psychological treatment and/or counseling records to you. Fill in the name on the person you want records for on the "(name of person signing)" line and fill your name and address in the "release to" section. Have the person you want records for mail or FAX the completed form into the doctor(s) or therapist(s) you want records from. This form may also be modified to include specific records if necessary.
AUTHORIZATION FOR RELEASE OF PSYCHOLOGICAL / COUNSELING RECORDS
Date _________________________ To ____________________________________ _______________________________________
I, _________________________ (name of person signing)
Address: __________________________ Address: __________________________ City: ________________________, State ________ SS#: ________________________, DOB __________________