Resolve Records Request

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1. Requesting party completes the form below.

2. Responses will be forwarded to the applicable staff (therapist, administrative team, clinical director, supervisor, etc.).

3. Requesting party will be sent a short contract detailing Resolve's records request policies and procedures. Signature will be required to fulfill the request.

4. Administrative and clinical teams will coordinate and compile records.

5. Administrative team send records to the requesting party.

Your First and Last Name *

First and Last Name of the Client *

Client Date of Birth *

Email Address *

Phone Number *

Name of therapist: *

Relationship to Client *

Self

Custodial Parent

Non-Custodial Parent

GAL/Lawyer/Etc.

Other:

Required

What type of records are you requesting?

All records (session notes, initial assessment/diagnosis, treatment plan)

Session Notes only

Initial Assessment/Diagnosis only

Treatment Plan only

Appointment Dates only

Other:

Clear selection

Please provide any addition details you feel would be helpful for the clinician to know regarding your request:

Records requests are typically fulfilled within 1-7 business days after coordination between the administrative team and our clinical staff. Additionally, there are various factors that impact the turnaround time of these requests (ethical considerations, coordination with related parties, administrative capacity, etc.).

Please type "YES" below if you have read and understand the above statement.

Submit

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