Medical Records Request

Please complete the form below to request medical or clinical records from Youth Extensions, Inc.

Important: A valid Authorization for Release of Information (ROI) signed by the client or legal guardian must accompany this request. Requests submitted without a signed ROI cannot be processed.

(Please note this is not required if request is made by the legal guardian)

Consumer Name

Consumer Date of Birth

Requestor Information

Name of Person Requesting Records

Telephone Number

Fax Number

Email Address

Records Requested

Please select the records you are requesting.

Clinical Assessment Service Plan Other:

Authorization for Release of Information A signed Release of Information (ROI) is required in order to process this request. Please upload the signed ROI below.
(Please note this is not required if request is made by the legal guardian).

Authorization for Release of Information

Additional Notes (Optional)