form?

[Sandine]

State of Texas -(I hope this makes sense???), To request files from couseling that can be submitted in court - what is the affidavit I send them to request such?

 

[Ukiah]

AUTHORIZATION FOR RELEASE OF PSYCHOLOGICAL / COUNSELING RECORDS



Date _________________________
To ____________________________________
_______________________________________

I, _________________________
(name of person signing)

Address: __________________________
Address: __________________________
City: ________________________, State ________
SS#: ________________________, DOB __________________

hereby authorize you to release to:

(Your name)
(Your Address)
(Your Address)
Phone (XXX) XXX-XXXX
FAX (XXX) XXX-XXXX

any and all information including the diagnosis and records of any treatment, examination, summaries, and recommendations rendered to me during the period from [start date] to [stop date].

Please mail or fax any material to the person listed above. If faxing, please include a cover sheet with a statement of confidentiality.

A copy of the signed original record release may serve as the original release.


_______________________
SIGNATURE

_______________________
WITNESS


- - -- - -- - - - - - -- --- - - - - - -- - -- - --


You need to get a subpoeana to have it admissible in court.

[Edited by Ukiah on 05-10-2001 at 12:04 PM]

 

[Sandine]

Ukia,

Thank you so much!