CAPS Request for Review/Release of Records

Date Date / MM / DD YYYY
Name Name First Last
Phone Phone - ### - ### ####
Panther ID#
Email
FIU Email
Date of Birth: Date of Birth: / MM / DD YYYY
The request is for (check all that apply)

The request is for (check all that apply) Review of Treatment Summary Review of full record by a licensed mental health clinician Release of Treatment Summary Release of full record to a license mental health clinician Compliance with court-order Psychological Report - Cognitive/Achievement testing report
If you chose "review of full record" or "release of full record," please insert the name of the clinician and their license number here:

Put N/A if it doesn't apply
I understand that Federal and state laws and rules prevent the release offull psychological records to students/clients,unless the release is to another licensed psychologist or is ordered by court.

If the request is for the release of records to me, I release Counseling and Psychological Services from all liability that may arise in the misplacement or disclosure of the records.

I understand that the request will be completed within a reasonable time, not to exceed 30 days.

I understand that records shall not be releasedwithout written authorization from the student/client, unless ordered by the cour

This is the description of your section break.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature.

* Requests for records not made in person require notarized signature. Clear

Full Name

I understand this is a legal representation of my signature.

* Requests for records not made in person require notarized signature.