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LWC Records Release Request Form

Please complete this form in full to request a release of information or to obtain a copy of client mental health records. Individuals over the age of 18 must authorize the release of their own information. A fee may be required for records release. The fee may be paid by cash or credit card and must be paid in person or by phone prior to processing client’s records request. Please Note: Per Lake Worth Counseling Policy & Procedures, LWC does not release client progress notes and is able to provide a professional summary report only.

If you do not receive a reply for records request within 24 hours (during regular business hours M-F) or have any questions or concerns, please contact us for assistance.

Questions??

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Email

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Phone

(817) 238-0106

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Open Hours

Mon – Thu: 8AM – 8PM
Fri: 8AM – 5PM

Lake Worth Counseling Records Release Request Form

Records Request & Fee*
- Summary Progress Report & Tx Plan - $150.00
- Counselor Professional Letter - $150.00
- Psychologist Professional Letter/Form - $175.00 (hourly rate)
- Legal Records or Letter - $300.00
- Certified Mail Fee - $35.00
- Attorney Phone Consultation Fee - $225.00 (50 min.)
- Doctor/Specialist Referral/Brief Collaboration of Treatment - NO FEE
- Collaboration with School (counselor, teacher, administrator) - $150.00 or by appointment only
- Administrative Fees/Forms/Attendance Report - $65.00
Name of person making request*
First Last
Relationship to client*
Address*
Street Address City State ZIP Code
Phone*
I authorize Lake Worth Counseling to release or obtain information concerning myself/minor*

Client Name
Date of Birth*
MM slash DD slash YYYY
The information specified below may be released TO or FROM the following (self, spouse, school, work, doctor’s office, attorney)
Name/Company*
Relationship to client*
Address*
Street Address City State ZIP Code
Phone*
Fax
Email*
The specific purpose(s) for this records request is*
Coordination of treatment, parent release, attorney, school consult, etc…
** Your Message contains website links, please remove them to be able to submit your form. Thank you!
Place a select all specific medical information to be released, and list the specific dates of treatment*
- All Health Information
- Progress Notes
- Attendance
- Intake Summary
- Psychological Test Results
- Treatment Plan & Diagnosis
- Billing Information
- Telephone Consultation
All Health Information*

List the specific dates of treatment.
Progress Notes*

List the specific dates of treatment.
Attendance*

List the specific dates of treatment.
Intake Summary*

List the specific dates of treatment.
Psychological Test Results*

List the specific dates of treatment.
Treatment Plan & Diagnosis*

List the specific dates of treatment.
Billing Information*

List the specific dates of treatment.
Telephone Consultation*

List the specific dates of treatment.
Client understands and acknowledges the following statement:
I authorize LWC to receive or release my or a minor’s mental health records. After the above information is released, it may be re-released by the recipient and the information may no longer be protected by federal privacy laws or regulations. I may be charged a fee for any copies of my mental health records or my child’s medical record I request for myself or for use by others. Fees for copies are due and payable before copies are released. I may revoke this authorization at any time by notifying LWC in writing: susan@lwc.care. Unless otherwise revoked in writing, this authorization will EXPIRE one year from the date this form is signed.
Signature of Client/Parent or Legal Guardian*
Date*
MM slash DD slash YYYY
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"Best place to go to therapy. My daughter and I have had a beautiful experience here. We have grown so much and we are super excited for future results! Don't hesitate to get some help when you need it, everybody needs someone to talk to or guide them on the right path."

Miracle

"Lake Worth Counseling comes highly recommended, the team there are extremely efficient and help during your most vulnerable time. Top notch in my book!"

James D.

"So grateful for Lake Worth Counseling. After my sessions, I leave with a sense of peace no matter if there are tears or laughter."

Elisa

"Had a great visit with our counselor! She made us feel welcome and able to open up :)"

Maria

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We're Here Whenever You Need Us

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Email

info@lwc.care

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Phone

817.238.0106

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Open Hours

Mon - Thu: 8AM - 8PM
Fri: 8AM - 5PM

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Address

4516 Boat Club Road, Suite 106, Fort Worth, Texas 76135

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