Medical Records Request

PLEASE NOTE THE FOLLOWING:

If you are a current client, please speak directly with your provider to request your medical records. Former clients can submit a request using this form.
For your privacy, anyone age 18 or older must request their own records — we’re not able to accept requests from family members or loved ones on someone else’s behalf. We also cannot process any request without a valid Release of Information (ROI) form.
If it’s easier, you’re welcome to visit any Pennsylvania Counseling Services location to complete a Release of Information in person. Our staff will be happy to help you through the process.

Helpful Links:

Medical Records Request Form

Client Name

Date of Birth (MM/DD/YYYY)

Name of Person Requesting Records

Relationship to Patient

What is your relationship to the patient?

Previous Treatment Provider Name

Location Seen:

Approximate last date of service (MM/DD/YYYY)

Purpose of the records request

Please attach the completed release of information. (Accepted file formats are PDF, JPEG, PNG)