Request A Report

Use this form to request a report be sent to up to 4 people.  If you want a copy, be sure to include your email in one of the fields.

REQUEST TO SEND REPORT

* Your Name

* Last 4 digits of your SS#

* Date Report is Due (MM-DD-YYYY)

What type of report would you like us to send?
Basic Court/Payor Report (Program, Attendance, Abstinence, Progress)

Assessment Summary (With Recommended Program)

Full Assessment

Other Describe

Who should we send the report to?
1-Send To
1-Email

2-Send to
2-Email

3-Send to
3-Email

4-Send To
4-Email

By signing below, I hereby authorize the Release of Information to the people listed above.

* I have read and understand the full terms (Click to Read Now) of this Release of Information which includes (1) Authorization for my insurance company to re-disclose my information, (2) My records are protected and cannot be disclosed without written consent and (3) I may revoke this consent at any time in writing.

* Signature