OLD Client Request for Report, Medical Records, Form, or Letters

Please use this form to submit your request for the following: medical records, reports/letters prepared by your therapist, or other forms needing completed.
All requests can take up to 1 to 2 weeks for preparation and clinical approval. Any items needed sooner can be expedited, by request, for an additional fee of $12.

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Simple Form/Report (1 page or less) $30
Letters From Therapist $70
In Depth Forms/Reports (2+ pages) $120
Evaluations (Drug and Alcohol or Mental Health) $160
Medical Records (Cost waived for clients UNLESS you have a balance)
Expedite Fee $12

Costs associated with your request will be confirmed by an Elliott Counseling Group Team Member.

















Some forms or letters require a certain type of signature so please choose which one is needed:


In order to best serve you, please provide as much detail as possible regarding the materials that you are requesting in order to make sure that your request is completed accurately. If we need more information, we will be in touch with you. Examples of what is needed: what do you need the letter for, fax numbers, who is the letter/forms going to, what is the address for where it needs to be sent, etc.


If you have a form or document for your therapist to fill out, please attach here:






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